Nominations

First Name*

Last Name*

Middle Name

Address*

Town*

State*

Postcode*

Email*

Phone Number*

Speedway Australia Licence*

Speedway Australia Licence Expiry Date*

Driver Registered Club*

Car Registered Club*

Car Number*

Division

Second Driver Name (If Applicable)

Second Driver Speedway Australia Licence# (If Applicable)

Make of Car*

Model of Car*

Sponsor 1

Sponsor 2

Transponder Hire
YesNo

Transponder Number

Registered for GST*
YesNo

Registered Business Name*

ABN Number*

Account Name *

BSB No *

Banking Organisation *

Account No *

I agree to the Terms and Conditions above *