OFFICIAL USE ONLY

MEMBER REF:   2012/

DATE JOINED:                         /        / 2012

Fee Due :   £20 Adult   : £10 Junior

Paid :   Cheque   /   Cash   /   Paypal

First name     

Surname

Address

Postcode

Mobile Telephone Number

Home Telephone Number

E- mail Address

Car

Registration Number

“I declare that I shall not drive in any part of a competition which takes place on the public highway unless I hold a valid motor vehicle driving licence for cars (other than provisional). I am acquainted with and agree to be bound by the General Regulations of the MSA.”

Signature of Holder …………………………………

(Warning Notice A)

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