2011 Victorian Open State Titles

Proudly supported by VicKarts

5th/6th NOVEMBER 2011



Entry form



Pilot's name:



Email address:



Weight:



DIVISION: PRODUCTION / PERFORMANCE ( CIRCLE ONE )





Entry Fee


Price
Qty
Total

A.B.A MEMBERS



NON A.B.A MEMBERS ( includes insurance levy )



ALL ENTRIES AFTER 1st OCTOBER 2011 ( includes insurance levy )


$30.00



$40.00





$50.00



Total









I / WE WILL BE ATTENDING THE SATURDAY NIGHT DINNER

( COST NOT INCLUDED IN ENTRY FEE )



NUMBER OF PLACES ……….









Please make all cheques payable to: Melbourne Blokart Club and send with entry form to :- Ray Brett, 2 Red Plum Place, Doncaster East, Vic. 3109.

Fee's can be paid direct into the MBC account, BSB 033017 Acct No. 216597 Acct Name Melbourne Blokart Club Inc.



PLEASE INCLUDE YOUR NAME IN THE PAYMENT DETAIL LINE.



Entry form can be emailed to mcbrett@iinet.net.au









I agree to be bound by the racing rules that govern this event. I further acknowledge and agree that in consideration of the notice of race, I accept that my participation is at my own risk.





NOTE! there will be no refunds or rain-checks once payment has been made.





Signed:







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