Winton Historic Titles

Winton Historics

Rider's Name *

First Name

Rider's Name *

Last Name

Date of Birth *

Email Address *

Phone Number *

Current Ambulance Membership *

Address *

Suburb *

Postcode *

Club *

MA Licence Number *

MA Licence Expiry Date *

Next of Kin *

Next of Kin Contact Number *

Are you a Life Member of HMRAV?

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 *

BIKE DETAILS

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

Class *

LOG BOOK NUMBER *

Preferred Race Number

Make *

Model *

Capacity *

Year *

BIKE No.1 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 *

BIKE No.3 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.4 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 *

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