nominate 2021 Nomination Form Competitor Name* First Last Competitor Phone*Competitor Email* Nominated Section* AMCA National Formula 500 Dirt Kart Junior Sedan Street Stock Sprintcar Wingless Sprint Registered State and Number*i.e. NT 1Sponsors InformationMedical ConditonsNext of Kin*Relationship to Next of Kin*Next of Kin Mobile Number*Are you a current DSRDA Member?*Select oneYesNoNominations Purchase*How many meetings are you nominating for? Please ensure this number matches the number of meeting you are purchasing. Nominations will be voided if you have not purchased them. Price: $ 50.00 Quantity: Nominations Purchase*How many meetings are you nominating for? Please ensure this number matches the number of meeting you are purchasing. Nominations will be voided if you have not purchased them. Price: $ 100.00 Quantity: Select Meetings*Please select which meetings you are nominating for. Please ensure this number matches the number of meeting you are purchasing. Nominations will be voided if you have not purchased them. Round 1 - 1 May Round 2 - 8 May Round 3 - 22 May Round 4 - 4 June Round 5 - 5 June Round 6 - 11 June Round 7 - 12 June Round 8 - 26 June Round 9 - 2 July Round 10 - 3 July Round 11 - 10 July Round 12 - 24 July Round 13 - 31 July Round 14 - 14 August Transponder HirePlease ensure the number of transponder hires entered correlate with the number of meetings you have nominated for. Transponder hire will be voided if you have not purchased them. Price: $ 25.00 Quantity: Supplementary Regulations*I declare that I have read and understood the supplementary regulations that will be in effect and the nominated race meeting/s and will adhere to them at all times. I accept any and all applicable penalties should they be breached by myself or an associated member of my nomination. I Accept COVID-19*I understand that the DSRDA has implemented a COVID-19 Management Plan and will adhere to all directional information displayed throughout the venue i.e. social distancing, sanitation requirements etc. I also understand the information provided in this nomination form may be used for contract tracing and notification purposes only. I Accept Coupon Total $ 0.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name
