Southland Sports Car Club Entry Form
Date of Meeting *
Class Entered
Transponder Number
Sponsors - for Program
Drivers Name *
Driver Detail *
Physical Address
Postal Address for Entry Details *
Email Address *
Home phone *
Business Phone
Mobile Phone *
Fax Number
Competition Licence Number *
Licence Expiry Date *
Licence Grade
Financial Member of the following Motorsport NZ Member Club, please name club *
Club Membership Expiry Date
Age Group - required for statistical purposes
Date of Birth
Entrant Name - to be completed in all cases if Entrant is other than the Driver
Postal Address
Email Address
Home Phone
Business Phone
Mobile Phone
Fax Number
Entrants Licence Number
Licence Expiry Date
Vehicle Details - Vehicle Make *
Vehicle Model *
Vehicle Colour
Permenent Race Number
Log Book No *
Capacity in cc *
Turbo or Rotary *
Certificate of Description (Schedule K or T & C where applicable)
Certificate of Description
Historic or Classic Vehicles - please complete the following, tick the appropriate box below to confirm which appendix six schedule the vehicle complies with
Vehcile Complies with
Refer to the current Motorsport Manual appendix 6 section 3 - vehicle classification part 2 - to complete the above
Year of Vehcile Manufacture
Complete if GST Registered
GST Registration Number
Name of Person / Company / Team Registered
Entry Fees *
 Entry Fee $170.00
 Late Entry $40.00
Other Fees
 SSCC Accident Assistance Fund $40.00
 Transponder Hire $40.00
Indemnity *
 I have read and understand the supplementary regualtions
 Total: $

1. Indemnity:

I have received or read the Supplementary Regulations and all other regulations or Articles as determined in the Appendices and Schedules of the current New Zealand Motorsport Manual for the event I am entering and agree to be bound by them and by the National Sporting Code of MotorSport New Zealand Inc.

In consideration of the acceptance of this entry and of my being permitted to take part in the Meeting or Events detailed, I agree to save harmless and keep indemnified MotorSport New Zealand Inc., The MotorSport Company Ltd., and it's Shareholding Car Clubs, and Race circuit owner / operators. All the owners and tenants of private property traversed, and the respective officials, fellow competitors, servants, representatives and agents from and against all losses, actions, claims, expenses and demands in respect of death, injury, loss or damage to persons or property of myself, my drivers, passengers or mechanics or any other persons whatsoever howsoever caused arising out of or in connection with this entry or taking part in the events this entry covers specified notwithstanding that such death, injury, loss or damage may have been contributed to or caused by the negligence of the Inviting Club or MotorSport New Zealand Inc or any of their respective officials, servants, representatives or agents or by any other person.

2. Ability to Control a Vehicle Declaration by Driver:

I declare that should I at the time of any event this entry form relates to be suffering from any disability of any kind whether permanent or temporary which is likely to detrimentally affect my control of my automobile or my fitness to drive, I will not participate.

3. Vehicle Conformance with Schedule A Declaration by Driver:

I declare the vehicle detailed on this entry form complies with the vehicle safety items set out below and will be presented on request to an appointed scrutineer or Technical Officer complying at all times with the safety and eligibility requirements detailed in the National Sporting Code and its Appendices and Schedules.

CATEGORY 1, Critical Safety

Helmets, Protective, Clothing, Brakes, Fire Extinguisher Systems, Fuel Tanks / Fillers, Roll Protection, Road wheels, Safety Harness / Harness Anchorages, Seats / Mounts, Steering, Suspension, Tyres

CATEGORY 2, Non-Critical Safety

Ancillary Components, Catch Tanks, Exhaust System, Flexible Hoses / Lines, Reverse Gear, Starter Motor, Throttle Return, Batteries, Ignition Switch / Circuit Breaker, Lighting Systems, Wipers / Demisting, Wiring, Bulkheads, Chassis / Bodyshell / Cockpit, Exterior Appearance, Panels / Covers, Towing Eyes, Windows

CATEGORY 3, Non Safety

 Ballast, Competition Numbers, Radio Transmitters

I acknowledge that where any breach of the Safety Schedule is found during a Scrutineering Audit I will be subject to penalties under the National Sporting Code and my signature below indicates my acceptance of this undertaking.

4. Consent:

I consent to the details contained on this form being held by MotorSport New Zealand Inc and/or the Inviting Clubs for the purpose of the promotion and benefit of the Race Meetings or Events concerned, and Motorsport in general. I acknowledge my right to access and correction of this information. This consent is given in accordance with the Privacy Act 1993.

I also authorise the medical providers of the event to disclose medical information relevant to illness or injury sustained during the above mentioned event to MotorSport NZ and it's officials.

Note: If Driver and entrant are different, we require you both to sign an idemnity at documentation.  All drivers will be required to sign Idemnity form at documentation.