2012 Queensland State Dressage Championships - Equestrian ...

SUMMARY OF FEES
ENTRY FORM TWO (2 of 7)
Rider Details:
Name:
Address:
Suburb:
Contact B/H:
Email:
Regional Rider: Regional Area:
Divisional 2 Rider (If you do not tick this, you will be considered Div 1) : :
EA Number:
Postcode::
Mobile:
Fax:
Masters Trophy: DOB: ___________
Junior Trophy:
Welcome BBQ – Friday evening - number attending @ $10 pp = x $10 = $
Summary of Fees:
Total entry fees (Form One) $
Total stable fees (Form Three) $
Total camping fees (Form Three) $
Total Welcome BBQ at $10 per head $
Total VIP Cocktail Party - Saturday night (Form Five) $
COMPULSORY ADMINISTRATION FEE PER HORSE/ PONY ENTRY $30.00 (nonrefundable
$30-00
and including Ambulance Levy)
Less Regional area subsidiary ($200) – refer Form 7 for explanation $
TOTAL $
This document acts as your TAX INVOICE / RECEIPT - please retain a copy for your records
I have read and accept all conditions of entry and I understand that my signature to this document constitutes a complete and
unconditional release of all liability to Equestrian Australia Ltd, including all its State Bodies, Coaches and Affiliated Clubs, to the
greatest extent allowed by law in the event of me and/or the children under my care, suffering injury or death.
Signed Competitor/Guardian: ________________________________________ Date: __________________
Important notice for all competitors:
To reduce post event administration workload we require that all riders/owners provide credit card details when submitting
their entries for this event.
Any shortfall in entry fees at the time of entry will be charged to the credit card and outstanding payments due to changes to
entries such as increase in stable days, camping and other charges will be charged to this credit card. Details of additional
charges can be provided. No stable bond is required however the venue charges cleaning fees for stables left dirty. Fees for
stables/private tack rooms not clean on departure will be charged to this credit card post event - post event refunds will be paid
to this credit card.
Payment Details:
Only credit card payment are accepted:
Visa Mastercard Bankcard Credit Amex
Card Payment: Value of $ ____________________
Card No: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Expiry Date: ____ / ____
Cardholder’s Name: _____________________________________________________________________________________
Signature: _____________________________________________________________________________________________
2012 Qld State Dressage Championship (as from 13 th Aug 2012) Page 12 of 18