Entry Form | myrtlefordalpinerally.com

Hi all!

We have an Alpine Rally Indemnity Form 2013 that must be filled out to enter the race.

“Please print out the indemnity form fill it out, bring it with you and sign it on the day” CLICK HERE FOR FORM

Also below is the Entry form for The Myrtleford Alpine Rally 2013 that can be filled out online.

Please contact the boys if you have any questions.

COSTS: $120.00 per rider

First name*

Last name *

Your Address*

Email*

Phone Number*

Date of Birth*

Bike Make*

Bike Model*

License Number: (not MA) *

Rec/Rego Number *

Any other details you would like to add

Debit Card Payment:

Please tick this box if paying by direct debit card and see the following account details to pay. Payment: $120.00 ---- Bsb: 803-070 --- Acc: 78611 --- Ref: ( your full name) --- These details will also be emailed to you.

Credit Card Payment:

Please tick this box if you would like to use credit card payment and fill in card details below.

Mastercard OR Visa

Card number

Expire Date

month

Year

Last 3 digits on rear of Card

To avoid delays in payment please double check all information before clicking submit.