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Licence Application/Renewal Superlicence Endorsement - 2021

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Licence Application/Renewal Superlicence Endorsement - 2021 Licence Application/Renewal Superlicence Endorsement - 2021 This form is for those wanting to apply for a Motorsport Australia Superlicence endorsement. Please note this form must be submitted to: Member Services, PO Box 172, Canterbury VIC 3126, RECEIVED STAMP HERE or emailed to [email protected] (OFFICE USE ONLY) MEMBER NUMBER Criteria Each Driver in the Supercars Championship must hold a Motorsport Australia Superlicence in addition to the minimum of an FIA International Grade C licence. An application for a Motorsport Australia Superlicence must be submitted to Motorsport Australia Member Services on the approved form. To qualify for a Motorsport Australia Superlicence each applicant must satisfy the following criteria: (tick all satisfied criteria) a. Hold a minimum of an FIA International Grade C licence; and b. Be a minimum of 17 years of age; and c. Accumulate a minimum of 13 points under either the FIA (refer ISC Appendix L) or Motorsport Australia Superlicence points system during the 5 years prior to the application (Page 3) In addition to the above each application also must satisfy at least one (1) of the following criteria: (tick all satisfied criteria) i. Be one of the first six (6) of the final classification of the previous year’s Supercars Australia Super2 Series. If one (1) or more Driver/s currently holding a Motorsport Australia Superlicence are within the first six of the final classification, eligibility for a Motorsport Australia Superlicence shall extend up to a maximum of the first eight (8) of the final classification of the previous year’s Series; or ii. Have competed in a minimum of 3 rounds of the Supercars Championship within the last 5 years or; iii. Have competed in a minimum of 6 rounds of the Supercars Super2 Series within the last 3 years or; iv. Hold a minimum of a Gold FIA Driver Categorisation. An application with supporting documentation for dispensation for items (i), (ii), (iii) or (iv) above will be jointly considered by of a panel of Motorsport Australia senior management and the Supercars Commission. The application must demonstrate the applicant has the experience required to compete at a competent level under the expected conditions experienced during all formats of competition of the Supercars Championship. Details SURNAME GIVEN NAMES DATE OF BIRTH — — GENDER EMAIL MOBILE PHONE ADDRESS SUBURB POSTCODE OFFICE USE ONLY MEMBER NUMBER DATE — — RECEIPT NO. AMOUNT $ MEDICAL TYPE OF MEDICAL INTERNATIONAL NATIONAL — — EXPIRY Motorsport Australia ABN: 55 069 045 665 Mail: PO Box 172 Canterbury LPO, VIC 3126 Phone: +61 3 9593 7777 Hotline: 1300 883 959 21/V2 pg. 1 motorsport.org.au © Confederation of Australian Motor Sport Ltd. trading as Motorsport Australia Licence Application/Renewal Superlicence Endorsement - 2021 Further Details EMERGENCY CONTACT NAME (1) EMERGENCY CONTACT NUMBER (1) EMERGENCY CONTACT NAME (2) EMERGENCY CONTACT NUMBER (2) DO YOU HAVE AN AUSTRALIAN CITIZENSHIP OR PERMANENT RESIDENCY? YES NO IF ‘NO’ NATIONALITY OF PASSPORT If 'NO', you are required to provide documentary evidence of your Australian Status. This can include: Appropriate section of your passport, utility bill showing your residential address, or a statutory declaration indicating that you are a resident of Australia. Payment (Non-Australian ASN Only) Fee: $500.00 Paying by (please tick appropriate box) Credit Card details Cash Name on card (Only if paying in person at Motorsport Australia House, VIC. Cash is not to be sent via any postal service) Card number Cheque/Money Order (Made payable to “Motorsport Australia”) Card expiry / CVV Credit Card Card type Visa Mastercard (Please complete details. Please note that American Express is not able to be used for payment) Signed Declaration (must be completed by all applicants) ANY APPLICANT MAKING A FALSE DECLARATION IS LIABLE TO REFUSAL AND CANCELLATION OF INSURANCE COVER I accept the conditions of, and acknowledge the risks arising from, attending or participating in Motorsport Activities being provided by Motorsport Australia and the Entities. I agree to be bound by the rules, regulations and policies of Motorsport Australia at all times as a condition of participating in this activity. The information I have entered into this form is true and correct and I will advise Motorsport Australia immediately if any of the information I have given is no longer true and correct. I have read, understood, acknowledge and agree to the above including the exclusion of statutory guarantees, warning, assumption of risk, release and indemnity. SIGN HERE DATE — — Parent/Guardian Consent (must be completed for all applicants under 18 years of age) I, of am the parent/ guardian (tick applicable) of the above-named (‘Minor’) who is under 18 of age. I have read this document and understand its contents, including the exclusion of statutory guarantees, warning, assumption of risk, release and indemnity, and have explained the contents to the Minor. I consent to the Minor attending or participating in the event at their own risk. SIGN HERE DATE — — Your Privacy Motorsport Australia requires the above information to assess your suitability for the activity. The information provided by you may be used and disclosed to others by Motorsport Australia for the purposes of Motorsport Australia’s business. Motorsport Australia may not be able to permit you to undertake the activity if you do not provide all of the information requested above. Full details of Motorsport Australia’s privacy policy (including how you can access and correct your personal information and make a complaint) are available at Motorsport Australia’s website (motorsport.org.au). Motorsport Australia and its partners may send you direct marketing materials from time to time. This is in addition to relevant information which Motorsport Australia may send to you as part of Motorsport Australia’s services. Please tick this box if you do not want to receive direct marketing from Motorsport Australia or its partners. 1300 883 959 pg. 2 motorsport.org.au © Confederation of Australian Motor Sport Ltd. trading as Motorsport Australia Licence Application/Renewal Superlicence Endorsement - 2021 Motorsport Australia Superlicence Points System Points shall be allocated to a Driver under the Motorsport Australia Superlicence system based on their final classification in a Championship/Series as follows: Championship/Series 1st 2nd 3rd 4th 5th 6th 7th 8th 9th >9th Supercars Championship* 13 11 9 6 4 3 2 1 0 0 Supercars Development/Super2 Series 12 10 8 7 6 5 4 3 2 1 GT Endurance Championship 12 10 8 7 6 5 4 3 2 1 GT Championship 12 10 7 6 5 4 3 2 1 0 S5000 Drivers Championship/Gold Star 12 10 7 6 5 4 3 2 1 0 Formula 4 Championship* 12 10 7 5 3 2 1 0 0 0 TCR Series 10 8 7 6 5 4 3 2 1 0 Porsche Carrera Cup Series 10 8 7 6 5 4 3 2 1 0 Toyota Racing Series (NZ) 10 8 7 6 5 4 3 2 1 0 Super3/V8 Touring Car Series 10 8 7 6 5 4 3 2 1 0 ARG Trans Am Series 7 5 4 3 2 1 0 0 0 0 Toyota 86 Series 7 5 4 3 2 1 0 0 0 0 Porsche Sprint Challenge Series 7 5 4 3 2 1 0 0 0 0 GT Trophy Series 7 5 4 3 2 1 0 0 0 0 NZ Touring Car Championship 5 4 3 2 1 0 0 0 0 0 State Formula Ford Championship 5 4 3 2 1 0 0 0 0 0 NZ Formula Ford Championship 5 4 3 2 1 0 0 0 0 0 SuperUtes Series 5 4 3 2 1 0 0 0 0 0 Production Car Series 5 4 3 2 1 0 0 0 0 0 Touring Car Masters Series 5 3 2 1 0 0 0 0 0 0 Aussie Racing Car Series 5 3 2 1 0 0 0 0 0 0 Radical Cup 5 3 2 1 0 0 0 0 0 0 Sports Racer Series 5 3 2 1 0 0 0 0 0 0 Sports Sedan Series 5 3 2 1 0 0 0 0 0 0 Karting Championship (KZ2, KA1) 3 2 1 0 0 0 0 0 0 0 Note: Championships/Series are Australian unless specifically indicated *Eligible for FIA Superlicence and Motorsport Australia Superlicence points. All other categories are eligible for Motorsport Australia Superlicence points. Superlicence Points Please indicate all points accrued for Superlicence eligibility by listing your outright position for each year you finished in the championship/series. Refer to the points system above for all outright points. Year Championship/Series Outright Position Points 2017 2018 2019 2020 2021 TOTAL Total points must be no lower than 13 Please return to: Motorsport Australia Mail: PO Box 172 Canterbury LPO, VIC 3126 Email: [email protected] 1300 883 959 pg. 3 motorsport.org.au © Confederation of Australian Motor Sport Ltd. trading as Motorsport Australia Licence Application/Renewal Superlicence Endorsement - 2021 1300 883 959 pg. 4 motorsport.org.au © Confederation of Australian Motor Sport Ltd. trading as Motorsport Australia.
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