MotoX Entry Form

SPEEDSPOT CLUB CHAMPIONSHIP ROUND 1

26 January 2019

MSA Permit: MSA 15691
Info: Janet Buys (Race secretary)
Cellphone: 083 3850227
Email: janet@zone7.co.za

Chairman:
Johann Spies
Email: johann@zone7.co.za

Fax number: 086 2733379


NB NOTE
This form is for a single rider only! Please submit a separate form for each family member rider! You can enter 2 classes with one form.

Fields marked with (*) are compulsory. These fields must be completed for the form to be submitted correctly and successfully.

RACING INFORMATION
There will be NO ONE DAY event licences available at the event, please
Contact Lizelle on 021 5561026 or email Lizelle@motorsport.co.za

PERSONAL DETAILS

Gender *
MaleFemale
Age on Race Day *

First Name *

Last Name *

Email Address *

Cellphone Number *

Date of Birth *

MEDICAL & EMERGENCY

Medical Cover
MSA
Name of Emergency Contact *

Emergency Contact Number *

MSA LICENSE AND CLUB MEMBERSHIP

Medical Cover
YesNo
MSA License Number

Type of License
ClubRegionalNational

SpeedSpot MX Member *
YesNo
SpeedSpot MX Z Number
eg: Z8888

Racing Number *

Sponsors

Team Name

CLASS SELECTION
PLEASE READ CAREFULLY

If you enter more than one class, for your second entry use the Members / non members 2nd class entry drop down where the cost of entry is already discounted in the form.

Note:
If a 2nd or 3rd family member is entered, choose the discounted fee or members / non members 2nd or 3rd family member entry class on the next form.

Enter Class and secondary Class if necessary

Members / non members 1st Class Entry

Members / non members 2nd Class Entry

Members / non members 2nd or 3rd family entry
Discounted fee.
Please use this field when you enter the second or third family entry only.

NON SpeedSpot MX MEMBERS !! *
Add the amount related to the number of entry.

R0 for SpeedSpot members
Non Members Extra R50 for one entry
Non Members Extra R80 for two entries


TOTAL TO PAY: Calculate the total amount you owe *

If any question or comments, please type here

YOUR SCRUTENERING FORM

ALL Items must be marked "Yes"

Spokes front and Back *
YesNo
Wheel Bearing - F/B *
YesNo
Tyre/Rim - F/B *
YesNo
Brakes & Lever - F/B *
YesNo
Mud Guard - F/B *
YesNo
Sprocket Cover *
YesNo
No's on 3 Sides of Bike *
YesNo
Noise Control *
YesNo
Handlebar & Padding *
YesNo
Kill Switch *
YesNo
Control Levers *
YesNo
Foot Rests *
YesNo
Kick Starts *
YesNo
Self-Closing Throttle *
YesNo
Exhaust/Silencer *
YesNo
Helmet *
YesNo
Chest Protector *
YesNo
MX Boots *
YesNo
Gloves & Goggles *
YesNo


PLEASE READ CAREFULLY

I hereby declare that I will ride with all the above compulsory equipment as presented.
Side Stands Not Permitted!

TECHNICAL CONTROL AFTER ACCIDENT
If a motorcycle is involved in an accident, the Technical Steward must check the machine to ensure that no defect of a serious nature has occurred. However, it is the responsibility of the rider / mechanic to present the machine for the re-examination together with helmet & clothing.

I hereby accept the Declaration above. *

Declaration/Undertaking to be signed by every competitor – Section 3

I have read and understand GCR’s 93,94,99,121 and 122 of the MSA General Competition Rules 2019 and signify my/our agreement to abide by these
rules by submitting this entry form. I, the lawful parent/guardian of the above-mentioned competitor, do hereby grant permission for him/her to ride in the
above-mentioned event. If a competitor is a minor, this form must be submitted by the appropriate parent or guardian.

Declaration/Undertaking by the competitor *
If 18 years old or by the parent/guardian


EFT PAYMENT

SpeedSpot MSA
Capitec Bank
Branch Code: 47 00 10
Acc #: 1368246638
Reference: Name and Surname

Please email relevant documents to janet@zone7.co.za.

NB NOTE
This form is for a single rider only! Please submit a separate form for each family member rider! You can enter 2 classes with one form.

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