Burnouts Online Nomination Form Only

Date of Competition *

Name * First Last

Phone Number *

Email *

Address *

Class & Name of your Burnout Car *

Passenger - Yes/No PLUS Passenger Details - Name address, Mobile *

PAYMENT INFORMATION - Please deposit $50 for your pre-paid nomination Fee to Westpac Bank - BSB 034-128 Account 61-2300 - MSCC - Please put your name as a reference and indicate below your receipt number.

OR please supply below a VALID Credit Card number with Expiry date and CCV number and sign to indicate your approval of the payment of $50-00 nomination fee. Please ensure funds are available as payments unable to be processed will be charged $70-00 on the day of competition.

SCRUTINEERING: All cars must be scrutineered prior to competition - THE MARYBOROUGH SPORTING CAR CLUB (MSCC) RESERVES THE RIGHT TO ACCEPT OR REJECT ANY NOMINATION.
NOMINATIONS CLOSE THE WEDNESDAY of the week of the competition date @5:00PM (NO EXCEPTIONS).
I, HEREBY AGREE to indemnify and to keep indemnified the Promoter, Landholder, their agents and officials from all actions, suits, claims and demands for damages or any other expenses whatsoever arising out of, or relating directly or indirectly to or from the use by me on the MSCC, MaryboroughSpeedway Complex and its surrounds for the purpose of/or any purpose connected with practice and/or competitive racing and/or trails and/or motor events. I, further agree that I will promptly carry out any reasonable instructions from any Official of the MSCC and will not in any way, do or suffer to be done, anything contrary to the regulations of the said Club. No alcohol /glass containers are to be bought into the speedway complex.. I also understand that the nominated driver and his/her pit crew may appear in visual media (i.e. photographs, video footage) that is taken inside this 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 Maryborough Sporting Car Club.
Please Sign Name and Date *

Wufoo