Bursons Auto Parts Cullen Bullen Raceway- The Home Of Real Country Dirt Track Racing

Name
Email Address
Phone No
Racing Division
Club/Association
Licence/Insurance
Licence Number
Licence Expiry date
Car No & Prefix
Vehicle Make
Sponsor
Race Date
- April 13
- May 4
By completing this nomination form I acknowledge, understand and agree that it is a condition of my participation in the event that I agree to be bound by, and subject to, the Terms and Conditions of Cullen Bullen Raceway. PDMSC reserves the right to refuse entry and/or exclude any person, without any reason being given
I agree to be bound by the Memorandum of Articles of Association, Rules and Regulations, Constitution of the Club.
Parent/Guardian Consent
Parents/Guardian Signature
By signing the nomination form for this event I understand that the nominated driver and his/her pit crew may appear in visual media (i.e. photographs, video footage) that is undertaken inside the speedway complex and that it remains the property of the media personnel involved. I also agree to any visual media involving the nominated driver and his/her pit crew to be used by the associated media personnel and/or Cullen Bullen Raceway.
Send

Thank you for your nomination. If there is any more information we need we will contact you.

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Cullen Bullen Raceway