2018 VVMXC MEMBERSHIP APPLICATION

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:



City:


State:


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:






Age:

D.O.B:

Occupation:




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: