Please Note: An additional 2% handling charge will be added to payments made using Master Card and Visa Credit Cards
Credit Card Type:
(Required)
Credit Card No:
(Required)
Name On Card:
(Required)
Valid From (mm/yy):
(Required)
Valid To (mm/yy):
(Required)
Security No :
(Required)
Issue No :
(Switch Only)
Driver 1 Details
Drivers Name:
(Required)
Race Licence No:
(Required)
Licence Grade:
(Required)
Club Membership No:
(Required)
Home Town/Country:
(Required)
Address:
(Required)
Town/City:
(Required)
County/State:
(Required)
Post Code:
(Required)
Daytime Tel No:
(Required)
Evening Tel No:
(Required)
Mobile Tel No:
(Required)
Email Address:
(Required)
Does the driver have any disability or is the driver taking any prescribed drugs which should
be notified to the Circuit medical staff:
(Required)(if yes please give details below)
Details of Disability:
DECLARATION:
I declare I have been given the opportunity to read the General Regulations of the Motor
Sports Association and, if any, the Supplementary Regulations for this event and agree to
be bound by them. I declare that I am physically and mentally fit to take part in the event
and I am competent to do so. I acknowledge that I understand the nature and type of the
competition and the potential risk inherent with motorsport and agree to accept that risk.
Further I understand that all persons having any connection with the promotion and/or
organisation and/or conduct of the event are insured against loss or injury caused through
their negligence.
To the best of my belief the driver(s) possess(es) the standard of competence necessary for
an event of the type to which this entry relates and that the vehicle entered is suitable
and roadworthy for the event having regard to the course and the speeds which will be reached
I understand that should I at the time of this event be suffering from any disability whether
permanent or temporary which is likely to affect prejudicially my normal control of the vehicle,
I may not take part unless I have declared such disability to the ASN, who have, following such
declaration issued a licence which permits me to do so.
Any application form for a licence which was signed by a person under the age of 18 years was
countersigned by that person’s parent/guardian/guarantor, whose full names and address have
been given.
If I am the parent/guardian/guarantor of the driver I understand that I have the right to be
present during any procedure being carried out under the Supplementary Regulations issued for
this event and the General Regulations of the MSA
As you are completing this form electronically please select 'YES' in this box to confirm you
have read & understood the declaration above :
(Required)
NEXT OF KIN
Please complete name, address and telephone number of relative or friend who can be contacted in
the event of a serious accident.
Next of Kin Name
(Required)
Address:
(Required)
Town/City:
(Required)
County/State:
(Required)
Post Code:
(Required)
Telephone:
(Required)
Driver 2 Details
Drivers Name:
(Required)
Race Licence No:
(Required)
Licence Grade:
(Required)
Club Membership No:
(Required)
Home Town/Country:
(Required)
Address:
(Required)
Town/City:
(Required)
County/State:
(Required)
Post Code:
(Required)
Daytime Tel No:
(Required)
Evening Tel No:
(Required)
Mobile Tel No:
(Required)
Email Address:
(Required)
Does the driver have any disability or is the driver taking any prescribed drugs which should
be notified to the Circuit medical staff:
(Required)(if yes please give details below).
Details of Disability:
DECLARATION:
I declare I have been given the opportunity to read the General Regulations of the Motor
Sports Association and, if any, the Supplementary Regulations for this event and agree to
be bound by them. I declare that I am physically and mentally fit to take part in the event
and I am competent to do so. I acknowledge that I understand the nature and type of the
competition and the potential risk inherent with motorsport and agree to accept that risk.
Further I understand that all persons having any connection with the promotion and/or
organisation and/or conduct of the event are insured against loss or injury caused through
their negligence.
To the best of my belief the driver(s) possess(es) the standard of competence necessary for
an event of the type to which this entry relates and that the vehicle entered is suitable
and roadworthy for the event having regard to the course and the speeds which will be reached
I understand that should I at the time of this event be suffering from any disability whether
permanent or temporary which is likely to affect prejudicially my normal control of the vehicle,
I may not take part unless I have declared such disability to the ASN, who have, following such
declaration issued a licence which permits me to do so.
Any application form for a licence which was signed by a person under the age of 18 years was
countersigned by that person’s parent/guardian/guarantor, whose full names and address have
been given.
If I am the parent/guardian/guarantor of the driver I understand that I have the right to be
present during any procedure being carried out under the Supplementary Regulations issued for
this event and the General Regulations of the MSA
As you are completing this form electronically please select 'YES' in this box to confirm you
have read & understood the declaration above :
(Required)
NEXT OF KIN
Please complete name, address and telephone number of relative or friend who can be contacted in
the event of a serious accident.
Next of Kin Name
(Required)
Address:
(Required)
Town/City:
(Required)
County/State:
(Required)
Post Code:
(Required)
Telephone:
(Required)
Driver 3 Details
Drivers Name:
Race Licence No:
Licence Grade:
Club Membership No:
Home Town/Country:
Address:
Town/City:
County/State:
Post Code:
Daytime Tel No:
Evening Tel No:
Mobile Tel No:
Email Address:
Does the driver have any disability or is the driver taking any prescribed drugs which should
be notified to the Circuit medical staff:
(if yes please give details below).
Details of Disability:
DECLARATION:
I declare I have been given the opportunity to read the General Regulations of the Motor
Sports Association and, if any, the Supplementary Regulations for this event and agree to
be bound by them. I declare that I am physically and mentally fit to take part in the event
and I am competent to do so. I acknowledge that I understand the nature and type of the
competition and the potential risk inherent with motorsport and agree to accept that risk.
Further I understand that all persons having any connection with the promotion and/or
organisation and/or conduct of the event are insured against loss or injury caused through
their negligence.
To the best of my belief the driver(s) possess(es) the standard of competence necessary for
an event of the type to which this entry relates and that the vehicle entered is suitable
and roadworthy for the event having regard to the course and the speeds which will be reached
I understand that should I at the time of this event be suffering from any disability whether
permanent or temporary which is likely to affect prejudicially my normal control of the vehicle,
I may not take part unless I have declared such disability to the ASN, who have, following such
declaration issued a licence which permits me to do so.
Any application form for a licence which was signed by a person under the age of 18 years was
countersigned by that person’s parent/guardian/guarantor, whose full names and address have
been given.
If I am the parent/guardian/guarantor of the driver I understand that I have the right to be
present during any procedure being carried out under the Supplementary Regulations issued for
this event and the General Regulations of the MSA
As you are completing this form electronically please select 'YES' in this box to confirm you
have read & understood the declaration above :
NEXT OF KIN
Please complete name, address and telephone number of relative or friend who can be contacted in
the event of a serious accident.
Next of Kin Name
Address:
Town/City:
County/State:
Post Code:
Telephone:
Driver 4 Details
Drivers Name:
Race Licence No:
Licence Grade:
Club Membership No:
Home Town/Country:
Address:
Town/City:
County/State:
Post Code:
Daytime Tel No:
Evening Tel No:
Mobile Tel No:
Email Address:
Does the driver have any disability or is the driver taking any prescribed drugs which should
be notified to the Circuit medical staff:
(if yes please give details below).
Details of Disability:
DECLARATION:
I declare I have been given the opportunity to read the General Regulations of the Motor
Sports Association and, if any, the Supplementary Regulations for this event and agree to
be bound by them. I declare that I am physically and mentally fit to take part in the event
and I am competent to do so. I acknowledge that I understand the nature and type of the
competition and the potential risk inherent with motorsport and agree to accept that risk.
Further I understand that all persons having any connection with the promotion and/or
organisation and/or conduct of the event are insured against loss or injury caused through
their negligence.
To the best of my belief the driver(s) possess(es) the standard of competence necessary for
an event of the type to which this entry relates and that the vehicle entered is suitable
and roadworthy for the event having regard to the course and the speeds which will be reached
I understand that should I at the time of this event be suffering from any disability whether
permanent or temporary which is likely to affect prejudicially my normal control of the vehicle,
I may not take part unless I have declared such disability to the ASN, who have, following such
declaration issued a licence which permits me to do so.
Any application form for a licence which was signed by a person under the age of 18 years was
countersigned by that person’s parent/guardian/guarantor, whose full names and address have
been given.
If I am the parent/guardian/guarantor of the driver I understand that I have the right to be
present during any procedure being carried out under the Supplementary Regulations issued for
this event and the General Regulations of the MSA
As you are completing this form electronically please select 'YES' in this box to confirm you
have read & understood the declaration above :
NEXT OF KIN
Please complete name, address and telephone number of relative or friend who can be contacted in
the event of a serious accident.
Next of Kin Name
Address:
Town/City:
County/State:
Post Code:
Telephone:
Driver 5 Details
Drivers Name:
Race Licence No:
Licence Grade:
Club Membership No:
Home Town/Country:
Address:
Town/City:
County/State:
Post Code:
Daytime Tel No:
Evening Tel No:
Mobile Tel No:
Email Address:
Does the driver have any disability or is the driver taking any prescribed drugs which should
be notified to the Circuit medical staff:
(if yes please give details below).
Details of Disability:
DECLARATION:
I declare I have been given the opportunity to read the General Regulations of the Motor
Sports Association and, if any, the Supplementary Regulations for this event and agree to
be bound by them. I declare that I am physically and mentally fit to take part in the event
and I am competent to do so. I acknowledge that I understand the nature and type of the
competition and the potential risk inherent with motorsport and agree to accept that risk.
Further I understand that all persons having any connection with the promotion and/or
organisation and/or conduct of the event are insured against loss or injury caused through
their negligence.
To the best of my belief the driver(s) possess(es) the standard of competence necessary for
an event of the type to which this entry relates and that the vehicle entered is suitable
and roadworthy for the event having regard to the course and the speeds which will be reached
I understand that should I at the time of this event be suffering from any disability whether
permanent or temporary which is likely to affect prejudicially my normal control of the vehicle,
I may not take part unless I have declared such disability to the ASN, who have, following such
declaration issued a licence which permits me to do so.
Any application form for a licence which was signed by a person under the age of 18 years was
countersigned by that person’s parent/guardian/guarantor, whose full names and address have
been given.
If I am the parent/guardian/guarantor of the driver I understand that I have the right to be
present during any procedure being carried out under the Supplementary Regulations issued for
this event and the General Regulations of the MSA
As you are completing this form electronically please select 'YES' in this box to confirm you
have read & understood the declaration above :
NEXT OF KIN
Please complete name, address and telephone number of relative or friend who can be contacted in
the event of a serious accident.
Next of Kin Name
Address:
Town/City:
County/State:
Post Code:
Telephone:
Driver 6 Details
Drivers Name:
Race Licence No:
Licence Grade:
Club Membership No:
Home Town/Country:
Address:
Town/City:
County/State:
Post Code:
Daytime Tel No:
Evening Tel No:
Mobile Tel No:
Email Address:
Does the driver have any disability or is the driver taking any prescribed drugs which should
be notified to the Circuit medical staff:
(if yes please give details below).
Details of Disability:
DECLARATION:
I declare I have been given the opportunity to read the General Regulations of the Motor
Sports Association and, if any, the Supplementary Regulations for this event and agree to
be bound by them. I declare that I am physically and mentally fit to take part in the event
and I am competent to do so. I acknowledge that I understand the nature and type of the
competition and the potential risk inherent with motorsport and agree to accept that risk.
Further I understand that all persons having any connection with the promotion and/or
organisation and/or conduct of the event are insured against loss or injury caused through
their negligence.
To the best of my belief the driver(s) possess(es) the standard of competence necessary for
an event of the type to which this entry relates and that the vehicle entered is suitable
and roadworthy for the event having regard to the course and the speeds which will be reached
I understand that should I at the time of this event be suffering from any disability whether
permanent or temporary which is likely to affect prejudicially my normal control of the vehicle,
I may not take part unless I have declared such disability to the ASN, who have, following such
declaration issued a licence which permits me to do so.
Any application form for a licence which was signed by a person under the age of 18 years was
countersigned by that person’s parent/guardian/guarantor, whose full names and address have
been given.
If I am the parent/guardian/guarantor of the driver I understand that I have the right to be
present during any procedure being carried out under the Supplementary Regulations issued for
this event and the General Regulations of the MSA
As you are completing this form electronically please select 'YES' in this box to confirm you
have read & understood the declaration above :
NEXT OF KIN
Please complete name, address and telephone number of relative or friend who can be contacted in
the event of a serious accident.
