2021 Dayle ITM Goldrush Rally of Coromandel Entry Form

Class entered *

NZRC1 or 1A (4WD or GROUP NZ 4WD)NZRC2 (FIA GROUP N 2WD, R1, R2 AND R3) NZRC3 (OPEN CLASS 2WD)NZRC4 (HISTORIC CHALLENGE TROPHY)NZRC5 (NZ RALLY CHALLENGE TROPHY 4WD/2WD or GROUP A)Allcomers - Open 4WDAllcomers - Open 2WD

DRIVER DETAILS

Driver First Name *

Driver Last Name *

Driver Email Address *

Driver Mobile Number *

Driver Physical Address incl. City/Town and Postcode *

Postal Address (if different from physical)

Driver Date of Birth

Day

Month

Year

Driver Emergency Contact Name *

Driver Emergency Contact Mobile Number *

Contested less than 3 rallies? *

Driver Competition License Number *

Driver License Grade *

Driver Expiry Date of Competition License *

Foreign Competitor on non-MSNZ license? *

Driver Financial Member of (Name of Club) *

Driver Expiry Date of Car Club Membership *

Driver Civil Drivers License Number *

Driver Is your Civil Drivers License currently disqualified? *If YES, then you must sign a declaration at Documentation as per NSC 43(2)(b)

Co-Driver Details

Co-Driver First Name *

Co-Driver Last Name *

Co-Driver Email Address *

Co-Driver Mobile Number *

Co-Driver Physical Address incl. City/Town and Postcode *

Postal Address (if different from physical)

Co-Driver Date of Birth

Day

Month

Year

Co-Driver Emergency Contact Name *

Co-Driver Emergency Contact Mobile Number *

Contested less than 3 rallies? *

Co-Driver Competition License Number *

Co-Driver License Grade *

Co-Driver Expiry Date of Competition License *

Foreign Competitor on non-MSNZ license? *

Co-Driver Financial Member of (Name of Club) *

Co-Driver Expiry Date of Car Club Membership *

Co-Driver Civil Drivers License Number *

Co-Driver Is your Civil Drivers License currently disqualified? *If YES, then you must sign a declaration at Documentation as per NSC 43(2)(b)

Entrant Details (if applicable)

Entrant Name (if applicable)

Entrant Email Address

Entrant Physical Address

Entrant Competition License Number and Grade

Entrant Expiry Date of Competition License

Vehicle Details

Vehicle Make *

Vehicle Model *

Registration Number *

Engine capacity (cc's) *

Year of Manufacture *

Log Book Number *

Colour of Vehicle *

Other info

Name of Official representative authorised for the purpose of receiving official notifications via SPORTITYEach competitor is required to nominate ONE official representative authorised for the purpose of receiving any official notifications via SPORTITY, along with the respective contact (cellphone, Email).

Mobile Number of Official representative uthorised for the purpose of receiving any official notifications

Email Address of Official representative uthorised for the purpose of receiving any official notifications

Past experience to assist with seeding (Event, Seeded #, Finish Position)

Team Manager Name (NOT Driver or Co-Driver)This should be someone that we can call while the rally is on, someone that is not competing

Team Manager Mobile Number (NOT Driver or Co-Driver)

Team accommodation name, address and phone number

Recce vehicle make (if known)

Recce vehicle registration (if known)

Recce vehicle colour (if known)

Will you be doing reconnaissance? *

YesNo

Will you be ordering notes (from www.allports.nz)? Must answer yes if doing recce or registering in NZRC *

YesNoAre available at a cost of NZ$250 per set. Competitors can order direct through Neil Allport Motorsport website www.allports.nz

Entry Fees *

NZRC Cat 1-4 With optional advertising - $1,248NZRC Cat 5 - with optional advertising - $1,098Allcomers - 4WD (Non-NZRC) - $998Allcomers - 2WD (Non-NZRC) - $955Recce Fee - $50Coverage of the MSNZ Insurance excess of $3,500 (Cat 5 and Allcomers only) - $50Late entry fee (post 1700hrs on 18 August) - $100Without optional advertising proposed by the Organisers please add NZL$1,000LESS earlybird Clubmans discount (entry prior to Friday 16 July) - less $100

Buffet meal tickets - for the prizegiving function - $30 eachPlease enter the number of buffet meal tickets you will purchase (note pre-payment is required and tickets are limited, so first in, first served).

Sustainability: Please select your optional donation to the Mobile Field Teams at Predator Free Hauraki Coromandel Community Trust: *Please add the donation price on to your entry fee when making payment. Predator Free Hauraki Community Trust run a national Predator Free programme across Coromandel Hauraki to protect endangered species and the natural habitat. The Mobile Field Teams are conservation experts that will drive around the peninsula helping conservation projects on the ground.

I will pay by: *

Bank depositCredit Card *please note a 3% transaction fee appliesPayment can be made to The Motorsport Club bank account: Westpac 03-0207-0614958-00 (Driver's last name as reference)

Credit Card Number

Expiry Date

Name of Card holder

I authorise the entry fees and other fees indicated on my entry to be charged to my credit card, as well as a 3% transaction fee.

Yes

Driver: Do you wish to sign the indemnity electronically (with mouse or touch screen) or alternatively upload a signature picture? *

Electronically sign the Indemnity Upload a signature picture to sign the indemnity If the Driver is filling out the form, please sign electronically. Otherwise, please upload a picture of the Driver's signature

Driver: I have read and acknowledge indemnity (see link below) *

https://www.rallynz.org.nz/2021-goldrush-rally-of-coromandel-indemnity/

Driver: I have read and acknowledge indemnity (see link below) *

https://www.rallynz.org.nz/2021-goldrush-rally-of-coromandel-indemnity/

Co-Driver: Do you wish to sign the indemnity electronically (with mouse or touch screen) or alternatively upload a signature picture? *

Electronically sign the Indemnity Upload a signature picture to sign the indemnity If the Co-Driver is filling out the form, please sign electronically. Otherwise, please upload a picture of the Co-Driver's signature

Co-Driver: I have read and acknowledge indemnity (see link below)

https://www.rallynz.org.nz/2021-goldrush-rally-of-coromandel-indemnity/

Co-Driver: I have read and acknowledge indemnity (see link below) *

https://www.rallynz.org.nz/2021-goldrush-rally-of-coromandel-indemnity/

Class entered *

DRIVER DETAILS

Driver Age Group *

Co-Driver Details

Co-Driver Age Group *

Entrant Details (if applicable)

Vehicle Details

Other info

Will you be doing reconnaissance? *

Will you be ordering notes (from www.allports.nz)? Must answer yes if doing recce or registering in NZRC *

Entry Fees *

I will pay by: *

I authorise the entry fees and other fees indicated on my entry to be charged to my credit card, as well as a 3% transaction fee.

Driver: Do you wish to sign the indemnity electronically (with mouse or touch screen) or alternatively upload a signature picture? *

Co-Driver: Do you wish to sign the indemnity electronically (with mouse or touch screen) or alternatively upload a signature picture? *