2021 Brian Green Property Group NZRC Registration Form

Class entered *NZ1 - 4WDNZ1A - GROUP NZ 4WD NZ2 - FIA GROUP N 2WD, R1, R2 AND R3NZ3 - OPEN CLASS 2WDNZ4 - HISTORIC CHALLENGE TROPHYNZ5A - NZ RALLY CHALLENGE TROPHY 4WD* see Group A Rally Challenge option belowGroup A Rally ChallengeNZ5B - NZ RALLY CHALLENGE TROPHY 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

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

Driver ProfileOccupation, Favourite Rally Event and Why, Most Memorable Rallying Moment, Brief History of Rallying Activities (first started, when/how, successes, etc. Brief bullet points are fine)

Co-Driver ProfileOccupation, Favourite Rally Event and Why, Most Memorable Rallying Moment, Brief History of Rallying Activities (first started, when/how, successes, etc. Brief bullet points are fine)

Junior Driver Award: (LESS THAN 25 YEARS AT 1 JANUARY 2020)Yes

Please confirm your Date of Birth

PAYMENT (Full Season, due 1 April 2021)NZ1 & 1A - $850.00NZ 2, 3 & 4 - $550.00NZ 5A & B - $400.00

PAYMENT (Round by round, due 2 weeks before your chosen round)NZ1 & 1A - $250.00NZ 2, 3 & 4 - $200.00NZ 5A & B - $150.00

I will pay by: *Bank depositCredit Card *please note a 3% transaction fee appliesPayment can be made to the Rally New Zealand bank account: ASB 12-3011-0203851-00 (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: I have read and acknowledge indemnity (see link below) *YesPlease read the indemnity at https://nzrallychamps.co.nz/2021-new-zealand-rally-championship-indemnity/

Co-Driver: I have read and acknowledge indemnity (see link below) *YesPlease read the indemnity at https://nzrallychamps.co.nz/2021-new-zealand-rally-championship-indemnity/

NZRC Team Registration

A maximum of two (2) competitors are eligible per team

Team Name (if applicable)

Team Captain Name

Competitor One - Driver and Co-Driver Names and Category/Class

Competitor Two - Driver and Co-Driver Names and Category/Class

DRIVER DETAILS

Co-Driver Details

Entrant Details (if applicable)

Vehicle Details

Other info

NZRC Team Registration

A maximum of two (2) competitors are eligible per team

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Merran Brockie-David

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