Winton Historics 2+4

Online Entry Form - v3

If you are human, leave this field blank.

Rider's Name *

First Name

Rider's Name *

Last Name

Date of Birth *

Email Address

Phone Number *

Current Ambulance Membership *

Address *

Suburb *

Postcode *

MA Licence Number *

MA Licence Expiry Date *

Next of Kin *

Next of Kin Contact Number *

Club *

Are you a Life Member?

Yes

Sidecar Entry - Life Member

Yes

Sidecar Entry

Yes

Sidecar Passenger Details

Passenger's Name *

Date of Birth *

Phone Number *

Address *

Suburb *

Postcode *

MA Licence Number *

MA Licence Expiry Date *

Next of Kin *

Next of Kin Contact Number *

Current Ambulance Membership *

Club

Entrant / Sponsor

MA Licence Number

MA Licence Expiry Date

How Many Bikes Are You Entering *

additional to your sidecar

How Many Bikes Are You Entering *

BIKE DETAILS

DON'T FORGET TO BRING YOUR LOG BOOKS TO THE TRACK

LOG BOOK NUMBER *

Preferred Race Number

Make *

Model *

Capacity *

Year *

Class *

BIKE No.2 DETAILS

DON'T FORGET TO BRING YOUR LOG BOOKS TO THE TRACK

LOG BOOK NUMBER *

Preferred Race Number

Make *

Model *

Capacity *

Year *

Class *

I have acknowledged and agree to
abide by the Suplementary Regulations. *

Yes

View Suplementary Regulations here

Life Member Status - you only pay

Entry Fee Total ($AUD)

Securely PAY by Credit Card

HMRAV