2018 REGISTRATION FORM

LONGTON’S NORTHERN SPEED CHAMPIONSHIP,

LONGTON’S SPRINT SERIES &

LONGTON’S CHAMPION OF THREE SISTERS

Held under the General Regulations of The Motor Sports Association (incorporating the provisions of the International Sporting Code of the FIA) and the Club’s Supplementary Regulations.

Registration can also be submitted online at www.longton-dmc.co.uk

Please note that all registered contenders must be fully paid up members of Longton & District Motor Club. Please apply or renew your membership on the separate membership form.	Membership No (if known)

DRIVER INFORMATION
First Name	Surname
Gender	Date of Birth *
Address
Town	County
Post Code	Email
Tel (day)	Mobile

VEHICLE INFORMATION
Manufacturer	Model / Type
Year	Vehicle Reg. No	or Not road-going (tick)
Capacity	cc	Engine (if applicable)	Turbo / Supercharged / Rotary
Fuel	Petrol / Methanol / Diesel / Other	Class

CHAMPIONSHIP CHOICE
Longton’s Northern Speed Championship (£18)	OR	Longton’s Sprint Series (£14)
Longton’s Champion of Three Sisters	(FREE!)
Championship Stickers required	(two will be provided)
T-Shirt Size (Not applicable for Champion of Three Sisters)	S / M / L / XL / XXL / XXXL

* NORTHERN SPEED CHAMPIONSHIP COMPETITORS ONLY *
I wish to register for the Best Novice award	(optional)
I wish to register for the Road Going award	(optional)
I wish to register for the Seniors award	(optional if 60 years or over at 1st Jan 2018)

ADDITIONAL CHAMPIONSHIP T-SHIRTS
You can purchase up to 3 additional t-shirts of each size at £7 each. Please indicate the desired numbers below.
Small	X Large
Medium	XX Large
Large	XXX Large

Please continue overleaf for Fee Calculation & Payment details.

FEE CALCULATION
Entry fee for Longton’s Northern Speed Championship = £18 OR Entry fee for Longton’s Sprint Series = £14	£
Additional T-Shirts	@ £7 each	£
Total	£

PAYMENT OPTIONS
I wish to pay by cheque and enclose one payable to Longton & District Motor Club
OR	I wish to pay by Credit/Debit Card. (We accept Mastercard, Visa & American Express at no extra cost)
We cannot hold your card details on file, so if you wish to pay by card please provide some information on when is best to contact you.
Signature * (Parent/Guardian if under 18 years old)

Please ensure the form is fully completed and return to:

Gavin Leadbetter, LDMC Entries Secretary, 48 Lynton Avenue, Leyland, Lancashire, PR25 4HY

or scan and email to entries@longton-dmc.co.uk. For assistance, call 07788 885711.

FOR OFFICIAL USE ONLY
Entered in Wufoo	Membership Verified	Cheque No:	Cheque Date: