Membership Application FormStep 1 of 520%Membership Application Type* I am applying for membership I am renewing my membershipMembership Number*I have been nominated by* First Last Membership Number*Member detailsName* First Last Address* Street Address Suburb Australian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia State Post Code Mobile Phone*Home PhoneEmail Address* Enter Email Confirm Email I would like to register my competition vehicle with IPRA I would like to complete my driver profile for the IPRA NSW websiteCompetition informationPreferred Competition Number*Second Choice*Vehicle InformationMake*Model*Year Model*Swept Volume (cc)*Turbo* Yes NoLogbook Number*Year Built*Driver Profile InformationOccupationFacebook PageTwitterLinked InIPRA / Motorsport InvolvementWhat/Where was the first event that you ever competed in?This could be a Motorkhana, Skid pan, Supersprint, etc...What is the first year you ever raced?AchievementsWhen listing achievements please include the year that they were achieved.QuotePlease supply a brief description of why you like racing in Improved Production.Photo / ImagesMember PhotoAccepted file types: jpg, jped, png, Max. file size: 8 MB.Please upload a photo of yourself (head shot)Vehicle Photos Drop files here or Select filesAccepted file types: jpg, jped, png, Max. file size: 8 MB, Max. files: 3.Please upload up to 3 images of your vehicleVehicle and other detailsClassUnder 2LOver 2LMakeModelEngineGearboxDiffBrakesPit crew and helpersSponsorsHow many sponsors would you like to list?*012345Please note, that the listed sponsors must appear on your vehicleSponsor 1Sponsor 1 - NameSponsor 1 - PhoneSponsor 1 - EmailSponsor 1 - WebsiteSponsor 2Sponsor 2 - NameSponsor 2 - PhoneSponsor 2 - EmailSponsor 2 - WebsiteSponsor 3Sponsor 3 - NameSponsor 3 - PhoneSponsor 3 - EmailSponsor 3 - WebsiteSponsor 4Sponsor 4 - NameSponsor 4 - PhoneSponsor 4 - EmailSponsor 4 - WebsiteSponsor 5Sponsor 5 - NameSponsor 5 - PhoneSponsor 5 - EmailSponsor 5 - WebsiteAcceptance / PaymentMembership I am applying for* Racing Membership - $120 Social Membership - $45IPRA NSW will supply all Racing Members with a 2019 t-shirt as part of your membership. T-shirt size*SmallMediumLargeX Large2X Large3X Large I hereby apply to renew my membership or become a member of IPRANSW and if accepted, I agree to be bound by the rules & regulations of the IPRANSW. I hereby give permission for IPRA NSW to contact me via Phone, SMS or email at any time.To complete your application, please ensure both boxes above are ticked. Amount Due $ 0.00 Payment Type* Direct Deposit Credit Card (secure online)Credit CardMasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name Please ensure you direct deposit amount listed above to; BSB: 062 313 Acc: 10211610 Name: Improved Production Racing Association of NSWCAPTCHA
