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    Online Entry: 2017 V 4 & Rotary South Island Champs | Rotary Only Day

    Please read through the driver information on our website before completing this form.

    We recommend using Google Chrome or Firefox to complete this form.


    First Name:(*)
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    Contact Number:(*)
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    Email Address:(*)
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    Drivers Licence #:
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    All competitors are required to upload an image of your car for our records and to use in our gallery of competitors. Images must be less than 2mb, and either pdf, jpg, png or gif format.
    Upload a picture of your car <2mb
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    Is your Vehicle Registered?(*)
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    Do you have a current WOF?(*)
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    Number Plate:
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    Rotary Only Day
    Includes access to the Rotary Only Day on Friday 17th November 2017 from 12pm-5pm.
    Rotary Only Early Bird Entry: $50 (Available until 17th October)
    Rotary Only Online entry: $80 (Available 8th November - 15th November)
    Rotary Only Entry on the day: $100

    Entry fee covers 1 driver and 1 vehicle for Friday Only.
    Entry Desired:(*)
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    Free Tshirt size:(*)
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    Have won at our event before?
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    If so can you please tell us what ones
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    We appreciate your entry and aspire to provide a friendly, exciting and safe experience.

    Please enter the correct event online. If you decide on the day you wish to change to both days, you will need to pay the full price for the other day.

    Indemnity: We advise that all activities do carry a degree of risk and that by participating in the activities provided, you are expressly assuming those risks personally and are releasing 4 & Rotary Promotions 2006 Ltd, Levels Raceway and land owners and their officials, representatives and agents (hereinafter known as the promoter) from any liability, claims, losses, damages or expenses caused by any event including, but not limited to:
    - personal injury or death – acts which may be constructed as negligent or accidental
    - property loss or damage – any other loss, damage, suffering, emotional or nervous disorder.

    In participating in the activity I agree to the conditions set out as above and consent to the conditions below:
    1(a) I agree that my successors, executors, administrators and next of kin are bound by these terms and conditions.
    1(b) I agree not to commence any litigation or proceedings in relation to the risks and perils set out in 1 above and to indemnify the Promoter against any such claims.
    1(c) I confirm that I am physically fit and suffer no medical conditions that could put me or another person at risk during this activity.
    1(d) I consent to receive medical treatment in the case of injury, accident or illness during that activity and to indemnify the Promoter against any claims in respect of this treatment.
    2. I agree that any films, sound, video or other recordings of or during the activity can be used by the promoter at it's complete discretion without prior approval.
    3. Refunds are entirely at the discretion of the promoter. No express or implied warranty of safety shall result from scrutineering checks.

    Scrutineering checks are intended to assist the competitor in his/her own safety checks and are in no way a guarantee against injury or death to a spectator or the participants. We will not share, sell, or rent individual personal information with anyone without your advance permission or unless ordered by a court of law. Information submitted to us is only available to employees managing this information for purposes of contacting you or sending you emails based on your request for information and to contracted service providers for purposes of providing services relating to our communications with you.

    Entry fee will only be refundable if entry is withdrawn via email prior to 1st of November and an administration fee of $30 will be retained.

    Any change of Driver or Vehicle will occur a $30 admin fee.

    Acceptance Of Terms(*)
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    Card Type:(*)
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    Direct Debit:
    Payments are to be made to "4 and Rotary Promotions"
    Account Number: 03-0179-0294140-002

    Please use your Number Plate as a Reference and Last Name as the Particulars.

    Payments are to be made within two working days from submitting this form.
    Name On Card:
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    Card Number: (no spaces)
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    Expiry ( MM/YY ):
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    Submit Entry
    After clicking the SUBMIT button you will be redirected to a new page to let you know your entry worked. Entries are not charged automatically! Processing usually takes 1-3 working days.

    Once we process and validate your entry and credit card details we will then confirm your entry via email and issue you with your registration number. Keep an eye on your Junk Folder too as these can often end up there.

    If you still see your entry form please check for errors in red.