Online Nomination

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Name*

Email Address*

Phone No*

Racing Division*

Club/Association*

Licence/Insurance *

Licence Number*

Licence Expiry date*

Car No & Prefix*

Vehicle Make*

Sponsor

Date Selector

By completing this nomination form I acknowledge, understand and agree that it is a condition of my participation in the event that I agree to be bound by, and subject to, the Terms and Conditions of Cullen Bullen Raceway. PDMSC reserves the right to refuse entry and/or exclude any person, without any reason being given

I agree to be bound by the Memorandum of Articles of Association, Rules and Regulations, Constitution of the Club.

Parent/Guardian Consent*

Parents/Guardian Signature*

By signing the nomination form for this event I understand that the nominated driver and his/her pit crew may appear in visual media (i.e. photographs, video footage) that is undertaken inside the speedway complex and that it remains the property of the media personnel involved. I also agree to any visual media involving the nominated driver and his/her pit crew to be used by the associated media personnel and/or Cullen Bullen Raceway.

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Thank you for your nomination. If there is any more information we need we will contact you.