Divi 2 Hot Rod "*" indicates required fields DRIVER:* ADDRESS:* SUBURB:* P / CODE:* WORK PH: MOBILE:* EMAIL:* CLUB:* CAR CLUB PREFIX & NUMBER:* MAKE OF CAR:* Own Transponder* Yes No PERSONAL TRANSPONDER NUMBER:* VSC LICENCE NUMBER:* LOG BOOK NUMBER:* HiddenCurrent Date* MM slash DD slash YYYY Late Nomination Fees Price: Nomination with Own Transponder Price: Nomination Fee Price: NOTE: The VSC Inc. in conjunction with the promoting body reserves the right to accept or reject any nomination. Licence and Logbook numbers Must be entered on your nomination form.* I hereby agree to abide by the decisions of the Scrutineers & Officials when my car is scrutineered to the VSC Inc. Specification Book and the VSC Inc. Racing Rules & Regulations Book. I also declare that the above information is true and correct. NOTE: The VSC Inc. in conjunction with the promoting body reserves the right to accept or reject any nomination. Licence and Logbook numbers Must be entered on your nomination form. All nominations received are entitled to receive 1 free drivers t-shirt for your State Title.Please Select SizeSizeSmallMediumLargeX Large2X Large3X Large4X Large5X Large DRIVERS PROFILE The information below is for media and announcer purposes.Please keep your answer appropriate for public use.NAME NICKNAME AGE PARTNER'S NAME TOWN OCCUPATION CLUBS MEMBER OFEnter one on each lineMOST MEMORABLE RESULTSEnter one on each lineMOST RESPECTED COMPETITORS AND WHYEnter one on each lineFAVORITE TRACKS RACE CAR MAKE CHASIS TYPE ENGINE BUILDER CREW CHIEF CREW MEMBERS SPONSORSEnter one on each lineTotal Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Security Code Cardholder Name
