2012 Mt BAW BAW SPRINT

EXPRESSION OF INTEREST FORMCOMPETITION - TOUR -

DRIVER Name:

Address:

Town/Suburb: _ Postcode:

Phone: (M) (W) (Fax)

Email:

CO-DRIVER Name:

Address:

Town/Suburb: _ Postcode:

Phone: (M) (W) (Fax)

Email:

VEHICLE Make: Model:

(TBA acceptable) Year: Engine Capacity: Reg No: Colour:

Forced Induction: Yes/No Four Wheel Drive: Yes/No Modified: Yes/No

Preferred Car Number: or or--------------------------------------------------------------------------------------------------------------------------

2012 Mt BAW BAW SPRINT (FEB 11 - 12) –$1,800.00*Tour Section - $600.00*

*Includes AASA Permit Fee

* From 1st January, 2010 a 3% surcharge will apply on all Credit Card payments

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Deposit Details- $500.00

I / We enclose cheque for $ (Payable to MOUNTAIN MOTORSPORTS P/L)OR

Please charge my credit card $ _ (M/C) (VISA) (B/C)

CREDIT CARD NO: EXPIRY:

CARD HOLDERS NAME:

SIGNATURE:

Please return completed form and $500 deposit to:

Mountain MotorsportsPO BOX 34Kilsyth 3137

Fax: 03 9779 6098

Email: peter@mountainmotorsports.com.au