First Name :
Last Name :
Date of Birth :	Year1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 MonthJan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 13th 14th 15th 16th 17th 18th 19th 20th 21st 22nd 23rd 24th 25th 26th 27th 28th 29th 30th 31st
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Address 2 :
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By completing this registration you will be eligible for points as both a driver and co-driver. If eligible you will also be entered in the Junior Championship (25 or under on the 01/01/2012)

DECLARATION

I have read and understood the regulations for this Championship and agree to be bound by them.

I AGREE

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