Please fill in this form to complete your VVMXC membership application You will be supplied with payment details or a link to our PayPal account upon submission.

= Required Field.

First Name:

Last Name:

Street Address:



Post Code:

IMPORTANT: Please provide your email address so that we can alert
you to any last minute race day changes and provide other important notifications.

Email Address:

Mobile Phone:

Work Phone:

Home Phone:




IMPORTANT: Please enter the name and phone number of your next of kin. You can enter the name and number in the one field

Next of Kin 1: (Name & Phone Number)

Next of Kin 2: (Name & Phone Number):

MA Lic No:

MA Lic Expiry:

Ambulance No:

Application Type:

Membership Type:

Please enter up to 3 preferred race numbers. If you have a current race number
and would like to keep it please enter it in the current race no field below.

1st Choice :

2nd Choice:

3rd Choice:

Current Race No:

Please enter the make model, year and class of any bike you wish to race below..

Bike 1 Make :

Bike 1 Model:

Bike 1 Year:

Bike 1 Class:

Bike 2 Make :

Bike 2 Model:

Bike 2 Year:

Bike 2 Class:

Bike 3 Make :

Bike 3 Model:

Bike 3 Year:

Bike 3 Class:

Bike 4 Make :

Bike 4 Model:

Bike 4 Year:

Bike 4 Class: