australian membership, license & number
INTERNATIONAL HOT ROD ASSOCIATION 1555 Palm Beach Lakes Blvd, Suite 1105 West Palm Beach, Florida 33401 Phone: 561-337-3015 Fax: 561-562-4020 [email protected]
2017 IHRA / AUSTRALIAN MEMBERSHIP, LICENSE & NUMBER (PAGE 1) THIS FORM AND THE COMPETITION LICENSE FORM MUST ACCOMPANY ANY NEW APPLICATION MEMBERSHIP & COMPETITION LICENSE: (Includes Membership Card) [ ] New Application [ ] Renewal
1) SELECT TYPE OF APPLICATION:
2) SELECT LENGTH OF MEMBERSHIP: [ ] $90.00 one year
[ ] $160.00 two years
[ ] $235.00 three years
3) SELECT CLASSES AND CAR NUMBERS: (NOTE – IF YOU DO NOT HOLD A CURRENT ANDRA LICENSE AND CAR NUMBER, YOUR CAR NUMBER WILL BE 6000 OR HIGHER)
CLASS _________________________
PERMANENT CAR NUMBER __________________
CLASS _________________________
PERMANENT CAR NUMBER __________________
CLASS _________________________
PERMANENT CAR NUMBER __________________ NOTE: ALL FUNDS IN U.S. DOLLARS
GENERAL MEMBERSHIP: Includes Membership Card – NO Competition License $80.00 one year ______
$140.00 two years ______
$205.00 three years ______
NOTE: ALL FUNDS IN U.S. DOLLARS
ASSOCIATE MEMBERSHIP: (Household must have a current full member at the same address) Subtract $10.00 per year __________
Full Member Membership # ________________ Expiration Date ______________
Name _______________________________________Email Address____________________________________ Address ___________________________________________________________________________________________ City ____________________________________________ State __________________ Post Code ________________ I am also an ANDRA
[ ] Yes
[ ] No
(If yes, please include copy of your ANDRA license with these forms
TOTAL AMOUNT PAID
PAYMENT METHOD [ ] Master Card
[ ] Visa
Credit Card # ____________________________
[ ] AmEx
Security Code ____
Exp.____ - ____ MONTH
SIGNATURE:______________________________________
YEAR
$ ALL FUNDS IN U.S. DOLLARS
By signing this application, I certify that I have read and agree to abide by all the rules, regulations and agreements of the IHRA rulebook and related publications. I understand that additions and amendments to the IHRA rulebook will appear online. (Effective 1/1/17)
INTERNATIONAL HOT ROD ASSOCIATION 1555 Palm Beach Lakes Blvd, Suite 1105 West Palm Beach, Florida 33401 Phone: 561-337-3015 Fax: 561-562-4020 [email protected]
2017 IHRA AUSTRALIA COMPETITION LICENSE FORM (PAGE 2) Each “NEW” applicant must enclose a photocopy of their state issued driver’s license with these forms. NOTE: a learner’s permit is not acceptable This Section To Be Filled Out By Applicant O New
O Renewal
Car#______________
O Upgrade
Note: (Page 1 is also required)
O (Copy of current ANDRA license required) if applicable
Class Applied For_____________________
Home Track _____________________________________
Name__________________________________________________________
Date of Birth __________________________
Address ________________________________________________________ Email ________________________________________ City _______________________________________
[ ] Full Bodied Car
State _______________
[ ] Altered/Funny Car
Post Code __________
[ ] Dragster
CLASS / CATEGORY [ [ [ [
] Top Fuel [ ] Top Bike ] Exhibition ] Competition ] Competition Bike
[ [ [ [
] ] ] ]
Pro Slammer Pro Alcohol Supercharged Outlaws Top Sportsman
[ [ [ [
] Pro Stock ] Pro Bike ] Super Stock ] Super Compact
[ ] Modified [ ] Modified Bike [ ] Super Street
[ ] Super Sedan [ ] Super Gas
[ ] Pro Radial
[ ] Junior Dragster
Copy of birth certificate required for all NEW Junior Dragster applications
[ ] Motorcycle 400 Metre Times
200 Metre Times
* Physical/Medical Required
* Physical/Medical Required
* Physical/Medical Required
* Physical/Medical Required
* Physical/Medical Required
* Physical/Medical Required
10.00- Slower - Car 9.50 - Slower - Bike N/A
6.40 - Slower - Car 6.15 - Slower - Bike * Physical/Medical Required
I, the undersigned, do hereby understand the full provisions of the competitor’s license issued to me by the IHRA, and accept the responsibility of operating my vehicle in a safe, sportsmanlike manner, and in accordance with all rules and regulations issued by the IHRA, and further, will accept any ruling by the IHRA suspending my driver’s license rights in the event that I fail to strictly follow all of my responsibilities. I agree to abide by all rules, regulations and requirements contained in the IHRA Australian rulebook, related publications and any amendments issued by the IHRA subsequent to the issuance of my license. I hereby agree and acknowledge that the Release and Waiver of Liability, Assumption of Risk, Indemnity and Rights Agreement which I have signed extends to all acts of negligence or other wrongdoing by the Releases, and is intended to be as broad and inclusive as is permitted under applicable law, and that if any portion thereof is held invalid, it is agreed that the balance shall remain in full force and effect.
Date: ______________________ Driver’s Signature ____________________________________________________________
This Section Is To Be Filled Out By Track/IHRA Official and Licensed IHRA Competitors Only (Current IHRA or ANDRA License # ___________ Code ________) If ANDRA transfer, passes not required but copy of ANDRA license required. (If passes are made on 200metre track, you will receive a license restricted to 200 metres) Facility Name _________________________________________________________________________ O 400 metres O 200 metres 1. 100 metre E.T. _________ MPH _________ Track Official Witness ____________________________________ 2. Half Pass E.T. _________ MPH _________ Track Official Witness ____________________________________ 3. Half Pass E.T. _________ MPH _________ Track Official Witness ____________________________________ 4. Full Pass E.T. _________ MPH _________ Track Official Witness ____________________________________ 5. Full Pass E.T. _________ MPH _________ Track Official Witness ____________________________________ LICENSED DRIVER SIGNATURES REQUIRED FOR CLASS A PRO DRIVERS ONLY
Date _________ _________ _________
IHRA/ANDRA Licensed Driver/Rider ______________________________ ______________________________ ______________________________
IHRA Member # _____________ _____________ _____________
Signature ___________________________________ ___________________________________ ___________________________________
Date Approved __________________ Approved By ________________________________________________________ 1/1/17 IHRA OR TRACK OFFICIAL ONLY
2017 IHRA / AUSTRALIAN MEMBERSHIP, LICENSE & NUMBER (PAGE 1) THIS FORM AND THE COMPETITION LICENSE FORM MUST ACCOMPANY ANY NEW APPLICATION MEMBERSHIP & COMPETITION LICENSE: (Includes Membership Card) [ ] New Application [ ] Renewal
1) SELECT TYPE OF APPLICATION:
2) SELECT LENGTH OF MEMBERSHIP: [ ] $90.00 one year
[ ] $160.00 two years
[ ] $235.00 three years
3) SELECT CLASSES AND CAR NUMBERS: (NOTE – IF YOU DO NOT HOLD A CURRENT ANDRA LICENSE AND CAR NUMBER, YOUR CAR NUMBER WILL BE 6000 OR HIGHER)
CLASS _________________________
PERMANENT CAR NUMBER __________________
CLASS _________________________
PERMANENT CAR NUMBER __________________
CLASS _________________________
PERMANENT CAR NUMBER __________________ NOTE: ALL FUNDS IN U.S. DOLLARS
GENERAL MEMBERSHIP: Includes Membership Card – NO Competition License $80.00 one year ______
$140.00 two years ______
$205.00 three years ______
NOTE: ALL FUNDS IN U.S. DOLLARS
ASSOCIATE MEMBERSHIP: (Household must have a current full member at the same address) Subtract $10.00 per year __________
Full Member Membership # ________________ Expiration Date ______________
Name _______________________________________Email Address____________________________________ Address ___________________________________________________________________________________________ City ____________________________________________ State __________________ Post Code ________________ I am also an ANDRA
[ ] Yes
[ ] No
(If yes, please include copy of your ANDRA license with these forms
TOTAL AMOUNT PAID
PAYMENT METHOD [ ] Master Card
[ ] Visa
Credit Card # ____________________________
[ ] AmEx
Security Code ____
Exp.____ - ____ MONTH
SIGNATURE:______________________________________
YEAR
$ ALL FUNDS IN U.S. DOLLARS
By signing this application, I certify that I have read and agree to abide by all the rules, regulations and agreements of the IHRA rulebook and related publications. I understand that additions and amendments to the IHRA rulebook will appear online. (Effective 1/1/17)
INTERNATIONAL HOT ROD ASSOCIATION 1555 Palm Beach Lakes Blvd, Suite 1105 West Palm Beach, Florida 33401 Phone: 561-337-3015 Fax: 561-562-4020 [email protected]
2017 IHRA AUSTRALIA COMPETITION LICENSE FORM (PAGE 2) Each “NEW” applicant must enclose a photocopy of their state issued driver’s license with these forms. NOTE: a learner’s permit is not acceptable This Section To Be Filled Out By Applicant O New
O Renewal
Car#______________
O Upgrade
Note: (Page 1 is also required)
O (Copy of current ANDRA license required) if applicable
Class Applied For_____________________
Home Track _____________________________________
Name__________________________________________________________
Date of Birth __________________________
Address ________________________________________________________ Email ________________________________________ City _______________________________________
[ ] Full Bodied Car
State _______________
[ ] Altered/Funny Car
Post Code __________
[ ] Dragster
CLASS / CATEGORY [ [ [ [
] Top Fuel [ ] Top Bike ] Exhibition ] Competition ] Competition Bike
[ [ [ [
] ] ] ]
Pro Slammer Pro Alcohol Supercharged Outlaws Top Sportsman
[ [ [ [
] Pro Stock ] Pro Bike ] Super Stock ] Super Compact
[ ] Modified [ ] Modified Bike [ ] Super Street
[ ] Super Sedan [ ] Super Gas
[ ] Pro Radial
[ ] Junior Dragster
Copy of birth certificate required for all NEW Junior Dragster applications
[ ] Motorcycle 400 Metre Times
200 Metre Times
* Physical/Medical Required
* Physical/Medical Required
* Physical/Medical Required
* Physical/Medical Required
* Physical/Medical Required
* Physical/Medical Required
10.00- Slower - Car 9.50 - Slower - Bike N/A
6.40 - Slower - Car 6.15 - Slower - Bike * Physical/Medical Required
I, the undersigned, do hereby understand the full provisions of the competitor’s license issued to me by the IHRA, and accept the responsibility of operating my vehicle in a safe, sportsmanlike manner, and in accordance with all rules and regulations issued by the IHRA, and further, will accept any ruling by the IHRA suspending my driver’s license rights in the event that I fail to strictly follow all of my responsibilities. I agree to abide by all rules, regulations and requirements contained in the IHRA Australian rulebook, related publications and any amendments issued by the IHRA subsequent to the issuance of my license. I hereby agree and acknowledge that the Release and Waiver of Liability, Assumption of Risk, Indemnity and Rights Agreement which I have signed extends to all acts of negligence or other wrongdoing by the Releases, and is intended to be as broad and inclusive as is permitted under applicable law, and that if any portion thereof is held invalid, it is agreed that the balance shall remain in full force and effect.
Date: ______________________ Driver’s Signature ____________________________________________________________
This Section Is To Be Filled Out By Track/IHRA Official and Licensed IHRA Competitors Only (Current IHRA or ANDRA License # ___________ Code ________) If ANDRA transfer, passes not required but copy of ANDRA license required. (If passes are made on 200metre track, you will receive a license restricted to 200 metres) Facility Name _________________________________________________________________________ O 400 metres O 200 metres 1. 100 metre E.T. _________ MPH _________ Track Official Witness ____________________________________ 2. Half Pass E.T. _________ MPH _________ Track Official Witness ____________________________________ 3. Half Pass E.T. _________ MPH _________ Track Official Witness ____________________________________ 4. Full Pass E.T. _________ MPH _________ Track Official Witness ____________________________________ 5. Full Pass E.T. _________ MPH _________ Track Official Witness ____________________________________ LICENSED DRIVER SIGNATURES REQUIRED FOR CLASS A PRO DRIVERS ONLY
Date _________ _________ _________
IHRA/ANDRA Licensed Driver/Rider ______________________________ ______________________________ ______________________________
IHRA Member # _____________ _____________ _____________
Signature ___________________________________ ___________________________________ ___________________________________
Date Approved __________________ Approved By ________________________________________________________ 1/1/17 IHRA OR TRACK OFFICIAL ONLY
