Late Model Racing Queensland Inc.

2016/2017 Queensland Title

Saturday 25th March 2017

Hi-Tec Oils Toowoomba Speedway

Nomination Form

Drivers Name_______________________________________

Address____________________________________________

_____________________________________

Contact Phone Number________________________________

Email _____________________________Car Number________

Sponsor Information__________________________________

___________________________________________________

___________________________________________________

Tow money for NSW $200 per car

Prize Money:
1st 1500.00 6th 400.00 11th 150.00 16th 150.00

2nd 1000.00 7th 300.00 12th 150.00 17th 150.00

3rd 700.00 8th 200.00 13th 150.00 18th 150.00

4th 600.00 9th 150.00 14th 150.00 19th 150.00

5th 500.00 10th 150.00 15th 150.00 20th 150.00

 MOTOR RACING IS DANGEROUS

Spectators, participants or guests are warned that Motor Racing is dangerous and accidents can happen. All care is taken to protect the
Public but spectators, participants and guests entering the Pit Area are warned that there is a possibility of an accident causing injury,
Death, or property damage. By purchasing and/ or using a ticket, official pass or stamped symbol that permits entry to the event and/or
the Pit Area, the spectator, participant or guests acknowledges that entry to the venue at which the event is held, and the Pit Area, has a
degree of danger and the owners, promoters, clubs, corporation, organisations, participants and other persons having any connection
with the promotion, organising or conduct of the event shall have no liability, either in tort or contact, for any personal injury or loss of
property, whether caused by negligence or otherwise, to the spectator, participant or guest, expect in regard to any rights those persons
may have arising under the Trade Practices ACT of 1974

NOTE: The organise reserve the right to change/alter entry to race procedure at any time as deemed necessary.

I/We hereby certify my/our acceptance of the above rules and conditions of entry and that the above declarations are true and correct.

LMRQ reserves the right to refuse an entry, without any reason being given. Entry is subject to LMRQ conditions of entry and
supplementary regulations.

LMRQ use the Speedway Australia points system as print in the current Australian Speedway Racing and Regulations booklet.

LMRQ reserves the right to use images of entrants and their vehicles in a variety of media used for the promotion of LMRQ.

Nomination Fees are non-refundable

Signature of Entrant: ____________________________________________ Date: ___________________

Signature of Drive: _____________________________________________ Date: ____________________

Where the entrant or driver is under 18 years of age the following must be completed.

Signature of Parent /Guardian: ___________________________________ Date: ____________________

TO BE FILLED OUT AND SIGNED IF REQUESTING PAYMENT BY ELECTRONICE TRANSFER

BSB #: ___________________ ACCOUNT #: _____________________________________

Name: __________________________________________ Signed: ________________________________

PAYMENT WILL BE MADE BY CHEQUE ONLY IF THE ABOVE IS NOT COMPLETE!

ENTRIES CLOSE 12TH APRIL, 2016. ALL LATE NOMINATIONS WILL START ROF

NOMINATION FEE $150.00 payable to LMRQ, There will be no late Nomination Penalties

BSB: 124 196 Account no: 20685467

Please use surname as reference or post to P.O. Box 308, Salisbury, Brisbane, QLD 4107

Steve van Zeeland 0412 719 599