Clone of Round 3 - CQMSC Khanacross Series

I acknowledge that I have read and understood the rules and regulations outlined in the Supplementary Regulations for this event
Competitor (Vehicle Owner)*

First NameLast Name
Driver*

First NameLast Name
Drivers Address*

Street Address

Street Address Line 2

CityState

Post Code
Drivers Mobile Phone Number*
Please enter a valid phone number.Format: 0000-000-000.
Drivers E-mail*
example@example.com
Come & Try
Drivers Motorsport Australia Licence*
Number
DayMonthYear
Expiry Date
Drivers Club Membership *

Club NameNumber
DayMonthYear
Expiry Date
Drivers Emergency Contact*

First NameLast NameMobile Number
Driver Signature*
DayMonthYear
0-1600cc4wd1601-2000ccLadies2001-3000ccJunior3001cc & overUTV
Car Details*

MakeModelYearCapacity
Registered
Registration (Third Party Extension required for the day)*

Registrarion NumberExpiry date
EFTPOS Payment on the Day

Or, Pay Now Via Card:*

Junior Entry

Junior entry into Khanacross. This does not include come and try license if required

$60.00AUD

Senior Entry

Senior entry into Khanacross. This does not include come and try license if required

$75.00AUD

Come And Try License

Come and Try license is a one-off day license to be added to your entry fee if you don't hold a motorsport Australia license.

$40.00AUD

Total

$0.00AUD

Credit Card

Apple Pay