Race Meeting Date

Name
Title
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
E-mail

 

Your Race car / class - what is your club prefix (ex... Maryborough 1 = M1 Modified Production)

Passenger Details OR  Junior Driver

Name
Age
Sex	Male Female

 

Do you declare you’re racing activities to be a hobby?

yes no

Do you have an ABN #

yes no

ABN number please :

If yes are you registered for GST

yes no

TRANSPONDER

Yes - i need to hire a Transponder please N0- i have my own and will supply the number on race day

PLEASE NOTE: * Prize, Tow, Travel or Appearance Money will be paid inclusive of GST.
If a competitor has ABN and does not provide number and does not declare their racing
to be a hobby, withholding TAX at a rate of 48% will be withheld and remitted to the
TAX Office. *Any prize, tow, travel or appearance money not claimed within 14 days
shall become disputed prize money as per Australian Speedway Racing Rules 4.23.12.
 There shall be no grounds for return after 14 days have lapsed since the running of the
 said meeting. * NO dual nominations will be accepted. ie. two drivers in one car in the
same division / one car in two divisions on the night

Your Sponsors = please list below

Scruitineering -All cars must be available for inspection between 1 pm and 3:30pm.
Cars will not be accepted after 3:30pm, unless by prior arrangement by calling MSCC.
Failing to notify MSCC on the numbers above and/or failing to attend the COMPULSORY
drivers briefing behind the control tower on time at 3:30pm SHARP, will result in a $25
 fine being deducted from your tow/prize money on that night of racing. Racing will
commence at 4 pm SHARP All cars must comply with 95 D.B.A.

Yes No

Media Consent

I give authorization for Maryborough Sporting Car Club Ltd , promoters of Maryborough
Speedway and its media personnel to use any photograph, video footage or sound
recording of the child in Maryborough Speedway publications, productions,presentations
or media.  This includes all electronic media such as the internet, websites, and social
networking sites.

Consent for use of Photographs/film/video etc. is  hereby granted to Maryborough Sporting
Car Club Ltd, advertising and promotional agencies, and their agents (collectively), the
irrevocable, unrestricted right to use, publish, display and distribute materials bearing
my name, voice, likeness or any other identifiable representation of myself.

These materials may appear in any form, style, colour or medium whatsoever now or
hereafter known (including, without limitation, photographs, videotapes, films, sound
recordings, software, drawings, prints, broadcast, internet and electronic media).

I agree that all materials containing any identifiable representation of me (including,
without limitation, all negatives, plates and masters of any photographs, files, prints or tapes)
 shall be and remain the sole and exclusive property of Maryborough Sporting Car Club Ltd.,
and I hereby assign any proprietary right I may have acquired in or to such material to
Maryborough Sporting Car Club Ltd.

I hereby release and forever discharge Maryborough Sporting Car Club Ltd from any and
all liability and damages relating to the use of my name, voice, likeness or any other
identifiable representation of me.

I hereby waive any right I may have to inspect or approve the finished materials or any
part or element thereof that incorporates my name, voice, likeness or any other identifiable
representation of myself.

I have agreed to the above in consideration of the opportunity given to me by Maryborough
 Sporting Car Club Ltd. to appear in these materials.

I acknowledge that I have fully read and understand this document and that I have had any
questions regarding its effect or the meaning of its terms answered to my satisfaction. I certify
that I am at least 18 years of age.



INDEMINTY CLAUSE: I, the undersigned DO HEREBY AGREE to indemnify and keep
 the Promoter, Landholder, their Agents and Officials from all actions, suits, claims and
demands for damages or any other expenses what so ever arising out of, or relating to
or from the use by me on the Maryborough Sporting Car Club circuit and it’s surrounds
for the purpose connected with practice and / or competitive racing or trials and or motor
events.  I further agree that I will promptly carry out any reasonable instructions from any
Official of the Maryborough Sporting Car Club and will not in any way, do or suffer to be
done, anything contrary to the regulations of the said club.  The DRIVER shall be responsible
for his or her Pit Crew according to the racing rules and regulations. Maryborough Sporting Car
Club Executive's & committee has the right to refuse any nomination.



 
(JUNIORS -  parents must fill in the nomination form or they wont be accepted)

Driver / Owner - must be over 18 to sign ! 

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