Blyton Park – August – Entry Form
Full August Weekend	(tick one)	NO LATE FEES IN 2018	Closing Date: 8th August
Saturday 11th August 2018	(tick one)	NO LATE FEES IN 2018	Closing Date: 8th August
Sunday 12th August 2018	(tick one)	NO LATE FEES IN 2018	Closing Date: 9th August
Held under the General Regulations of The Motor Sports Association (incorporating the provisions of the International Sporting Code of the FIA) and these Supplementary Regulations.

Data Privacy & Security Statement

The data collected in this form is used solely for the organisation of this event. We will not use it to contact you about anything other than matters relating to this event and we will not share your information with any other organisations.

Please complete the form in BLOCK CAPITALS and submit one form per event.

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

DRIVER INFORMATION
First Name	Surname
Gender	Date of Birth
Address
Town	County
Post Code	Email
Tel (day)	Mobile
Competition Licence No	Licence Type	Novice / Expert (see SRs 4.1.20 for definition of a Novice)
Club(s) (Those relevant to this event)
Do you hold, or have you ever held, a valid Road Traffic Act Licence?	Yes / No

ENTRANT INFORMATION (if applicable)
First Name	Surname
Company (if applicable)
Address
Post Code	Tel (day)	Mobile
Email	Entrants Licence No

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
Shared Car?	Other driver’s name	Who drives first?
Is your vehicle self-starting, at any part of the course?	Yes / No
If not, you are required to declare on this entry form the method of operation together with a detailed starting instruction. MSA Yearbook S7.1.6 Continue in the overflow box overleaf if required

Please continue overleaf for Championship, Emergency Contact & Payment details.

VEHICLE INFORMATION (continued from Page1)

CHAMPIONSHIPS
Longton’s Northern Speed Championship	Others (Those relevant to this event)
OR	Longton’s Speed Series
LDMC Membership No

CONTACT IN CASE OF EMERGENCY (Must be Parent/Guardian for competitor under 18 years old)
Full Name	Phone
Relationship to Driver
Same address as driver?	Yes / No If no, please continue below
Address
Town	Post Code

FEE CALCULATION
Entry Fee - £115 per day or £220 for both days	£
LDMC Membership Discount (£5 discount per day for LDMC Members)	£	Less
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	Fee Verified	Cheque No:	Cheque Date: