test – Targa New Zealand

Silver Fern Registration

Step 1 of 9

Driver 1
Last Name*
First Name*
Street*
Town / City*
Region / State
Country*
Email address*
Phone*
Mobile phone*
Sex*
Age group*
Emergency Contact Name*
Emergency Contact Phone*

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Driver Details
Competition licence number*
Licence Grade*
Expiry date*
Financial member of...*
Club membership expiry*
Drivers licence number*
Drivers licence expiry*

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Driver 2 (co driver)
Last Name*
First Name*
Street*
Town / City*
Region / State
Country*
Email address*
Phone*
Mobile phone*
Sex*
Age group*
Emergency Contact Name*
Emergency Contact Phone*

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Co Driver Details
Competition licence number*
Licence Grade*
Expiry date*
Financial member of...*
Club membership expiry*
Drivers licence number*
Drivers licence expiry*

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Team/Service Manager Details
Last Name*
First Name*
Email address*
Phone*

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Address for Communications
(Identify person responsible for receiving Event Communications)
Contact Name*
Postal Address for event Communications*
Email Address*
Fax

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Vehicle Details
Vehicle Make*
Vehicle Model*
Year of Manufacture*
Engine Capacity (cc's)*
Event
Class*

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Terms and Conditions
I have read and understand the Terms and Conditions*
- I understand
I have read and understand the Terms and Conditions HERE

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Payment
Silverfern 2016 Entry
Price:
Total
$ 0.00
Payment method*
If you would like to pay by credit card, we will call you for your credit card details.
I have made payment*
- I have made payment to the following account;
Bank Name
02-0404-0255632-00
$11,000.00 including GST
I would like more information on...
- Shipping and car transportation
- New Zealand customs requirements
- Vehicle rental services
- Accommodation

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