Anglesey Season Opener – Entry Form
Full April Weekend	(tick one)	NO LATE FEES SINCE 2017	Closing Date: 3rd April
Saturday 6th April 2019	(tick one)	NO LATE FEES SINCE 2017	Closing Date: 3rd April
Sunday 7th April 2019	(tick one)	NO LATE FEES SINCE 2017	Closing Date: 4th April
Held under the General Regulations of Motorsport UK (incorporating the provisions of the International Sporting Code of the FIA) and these Supplementary Regulations.

Please complete the form in BLOCK CAPITALS and submit one form per event. All fields are mandatory.

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 4.1.21 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?
Does the vehicle have a reverse gear?	Yes / No
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.

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 - £135 per day or £250 for both days	£
LDMC Membership Discount (£5 discount per day for LDMC Members)	£	Less
Our marshals are critical to ensuring our ability to run the event. The club provides marshals with breakfast, lunch and tea/coffee at each event, and overnight accommodation for full weekend events. If you wish to add a voluntary contribution to the fund, please enter an amount here	£	Plus
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)

COMMUNICATION PREFERENCES
We would like to keep you informed of news, events and offers that may be of interest to you. Please tick the options you would like to opt-in to below. You will be able to opt-out of these at any time, and we will not pass on your details to any other club or organisation. If you have previously opted in to these, we won’t add you again. You can review our Privacy Policy on the club website and/or email privacy@longton-dmc.co.uk for details of what you are currently opted into.
Club Bulletin	Club Events & Championships	Non-Club Events & Offers

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 events@longton-dmc.co.uk. For assistance, call 07788 885711.

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