"-----------------------------------------------------------------------------------------------------------------------

SURVIVOR CLIFFHANGER ( 3RD to 8TH APRIL, 2011  ) 

Competitors and Spectators: Please read the conditions before submitting your entry.

Make sure your medic form is also submitted with your entry

Competitor

Which Class? Challenge or Production

Team Name

Drivers Name

Navigators Name

Address:

Email address: (Will email instead of post)

Optional 2nd Email address:

Telephone number with contact name:

Additional Comments:  

		Select payment type Please Make Selection Cheque Money Order Direct Debit Visa or Mastercard I wish to pay by the month* Please Make Selection $100 per month $200 per month $300 per month $400 per month $500 per month Total Amount $
Credit Card Number	Mastercard Visa *note 1. 5% surcharge applies if paying by credit card
Expiry Date
Card Name

Post with a cheque or money order payable to Cliffhanger 4wd Events to 15 Nirvana Close, Langwarrin South Vic 3911.

Direct debit is also accepted. Account Name: Navrun BSB: 733138 ACCOUNT NO: 687165. WESTPAC.

Or fax your entry form on (03) 9776 6798 or telephone 0428 534 102

(Note: Credit cards are accepted, however a 1.5% surcharge will apply)