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Round 1- MRF FMSCIIndian National Rally Championship 2017 / COMPETITON NO.
(For official use)
Closing date for Standard Entries :
Tuesday, 18th July 2017 @ 2000 hrs / Closing date for Late Entries :
Thursday, 20th July 2017 @ 1700 hrs
ENTRYFORM / Entrant / Competitor / First Driver / Co-Driver
Team Name
Surname
First (given)Name
Place
Gender
Blood Group
Date of Birth
Communication Address
Telephone (business)
Telephone (private)
Mobile
Fax No.
Email Address
FMSCI Comp. Lic. No.
PAN
FMSCI IRC Reg.No.
Driving License No.
PA Policy Details / Policy No. / Amount / Issued by / Valid
From / Valid
Till
Driver
Co- Driver
Details of the Car
Make / Registration No.
Model / Capacity – cc
Year of Manufacture / Chassis No.
Group / Class / Engine No.
Homologation No. / Predominant Colour
Special Rally Cover Insurance Number / Company / Valid From / Valid Till
Name of Tuner

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Round 1 - MRF FMSCI Indian National Rally Championship 2017 / COMPETITON NO.
(For official use)
Sl. / Championship / Entry Fees
(with Optional Advertising) / Entry Fees
(without Optional Advertising)
1 / INRC / Rs. 35,000/- / Rs.50,000/- = Additional
2 / INRC 2 / Rs.30,000/-
3 / INRC 3 / Rs.25,000/-
4 / FMSCI 4WD CUP / Rs.20,000/-
5 / FMSCI 2WD CUP / Rs.20,000/-

Team Entrant ManufacturerEntry : Rs.35,000/- (Additional – per car). A team or commercial entry may consist of maximum of 3 cars per Championship. Late Entry Fees Rs. 5000/-.

For this entry form to be valid, it must be accompanied by the appropriate entry fees The entry fees can be paid either by Demand Draft in favour of “COIMBATORE AUTO SPORTS CLUB” payable at COIMBATORE or by Cash or by wire transfer.

BankCentral Bank of IndiaIFSC Code of BankCBIN0280908

BranchCoimbatore (908)SB A/c No.1407019402

Seeding Information
FIA Priority AYear : / FIA Priority BYear : / FMSCI Seed A / FMSCI Seed B
Declaration & Indemnity
I/We hereby make an application to participate in the above mentioned rally and certify that theparticulars of my vehicle as given overleaf are correct, that I/We have read the SupplementaryRegulations issued by Organisers for the said rally and agree to be bound by any of theInternational Sporting Code of the FIA, the General Prescriptions for 4W, Sporting Regulations andChampionship Regulations of FMSCI; as well as the undertaking on this entry form.
I have read the Regulations issued for this event and agree to be bound by them. In considerationof the acceptance of this entry, I agree to save harmless and keep indemnified the Government,the FMSCI, the Organisers, the FIA and their officials, the Sponsors, agents, representatives,employees and all persons assisting them in this event and all owners and tenants of privateproperty traversed by this event, from and against all actions, claims, cost, expenses and demandsin respect of death or injury to myself or any other person or persons or loss or damage to anyproperty including the car concerned in this event and test, if any or otherwise howsoever and notwithstanding that the same may have been contributed or occasioned by the negligence of theOrganiser and their official, agents, representatives, employees and all persons assisting them inthis event. The indemnity shall be binding on my heirs, executors and legal representatives. I/wedeclare that I/we shall not post any wrong and or provoking information/comment on socialmedia of any kind neither to any media personnel. All grievances / problems will be addressedthrough correct procedures as laid down in the sporting code, general prescriptions applicable tothe respective event and supplementary regulations of the event.
I/We also undertake to compensate and or settle all third party damages of any kind, caused byme/us, my representative/s or who so ever connected with me/us during the event.
I declare that the drivers posses the standard competence necessary for an event of this type towhich this entry relates, also that the vehicle entered is suitable and rally-worthy for the event. Iagree and undertake to abide by the rules and regulations framed for this event including theconditions precedent set out herein and all other rules and regulations, which may hereinafter beframed.
Finally I/We hereby acknowledge that I / We am / are fully conversant with the risk and dangers ofMotor Sports in general and this rally in particular which I/WE assume hereby.

Place:Date :

SignatureoftheEntrant / SignatureoftheDriver / SignatureoftheCo-Driver

Name,address& Signature ofthewitness:

1) / 2)

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Round 1 - MRF FMSCI Indian National Rally Championship 2017 / COMPETITON NO.
(For official use)
Media Information / Driver / Co-Driver
Name
Place
Date of Birth
Team
Championship Titles
INRC Debut
INRC Wins
Website
Career Highlights
2016
2015
2014
Favourite Motorsports Icon
Hobby
Any other
Signature of the Driver / Signature of the Co-Driver

Please send duly completed form to

Coimbatore Auto Sports Club

Shop No. 29, Nehru Stadium,

COIMBATORE –641 018.

Telephone: +91 422 2380065

E-Mail: Web site:

MRF Rally of Coimbatore 2017
Round 1 of 2017 MRF FMSCI INRC