Queensland Lighting Sprintcar

QUEENSLAND LIGHTNING SPRINT RACING ASSOCIATION QLSRA

EMAIL: [email protected] or [email protected] Mob: 0404 040 783

QLD TITLE REGISTRATION FORM – Season 2016/2017

I/We being the owner/s ______

Of (full address) ______State: ______P/C:______

Phone (H): ______(M): ______

Email: ______

In signing this registration I confirm the vehicle complies with the Queensland Lightning Sprint Racing Association Class Specifications.

Car Number: ______

State vehicle garaged: ______

Name of Driver/s:______

Colour (Main):______(Minor):______

Make of Engine:______

Engine Seal Number:______

Sponsors: ______

NOMINATION FEE: $100 REF: qldtitle (and your car number) Nominations Close: 12:00pm Noon Monday 20 March 2017

EFT details – Acc Name: QLSRA, HERITAGE BANK BSB: 638-010 Acc No: 13179365

Applicants Signature: ______Date: ______