Nominate

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 1

Sponsors Information

Medical Conditons

Next of Kin*

Relationship to Next of Kin*

Next of Kin Mobile Number*

Are you a current DSRDA Member?*

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: $ 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.

Transponder Hire

Please 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:

Transponder Number (If using own)

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

2021 Nomination Form