AGEUS RALLYSPRINT2017

ENTRY FORM

Closing date of entries: 28 March 2017 (22:00)

Send to form to:

RALLYSPRINT KLUB vAČR

Podkopná Lhota 136

Trnava 763 18, Czech Republic

Tel./Fax: +420577101232, +420 602723 407

Or by e-mailto:

Competitor / Driver / Co-driver
Team name
Surname
First name
Date of birth
Nationality
Address / 1. / 2. / 3.
Passport no.
Contact address
(use only one) / 1. / 2. / 3.
Phone
Fax
E-mail
Competition licence no.
Issued by
Driving licence no.
Issued in country
Team coordinator
Phone
E-mail

PODROBNOSTI O SOUTĚŽNÍM VOZIDLE

Producer / Number plate
Type / Engine capacity
Production year / VIN
Group / Class / Engine number
Homologation no. / Dominant colour
Country of registrat. / Tech. Passport no.
Organiser’s advertising accepted / YES - NO

ENTRANCE FEES

To be accepted the entry form must be accompanied by the appropriate entry fees,a receipt for the full amount paid to the entrants ASN,a banker´s draft or details of a bank transfer etc.

ENTRANCE FEE / with organiser’s advertising / without organiser’s advertising
Standard fee / 7.800CZK / 15.600CZK
Discounted fee – Juniors’ cup (under 17 years) / 5.600 CZK / 11.200 CZK

The insurance according to Art. 5.1 SR of 1.495CZK(or 340 CZKin Juniors’ cup under 17 years) can be paid together with the entry fee.

Bank: Česká spořitelna

Account number: 1416430359/0800, Swift: GIBACZPX, IBAN:CZ08 0800 0000 0014 1643 0359

Specific symbol: Driver’s competition licence number

INFORMATIONABOUT PRIORITY DRIVER

Driver: ......
Car: ...... Group / Class: ………………….
FIA A priority driver
FIA B priority driver
ASN priority driver / YES / NO
YES/ NO
YES/ NO / Previous FIA priority: YES/ NO
If yes, which … - year ……………
Previous ASN priority - year ……………
Winner of the national championship YES/ NO
If yes, which championship : ...... …...... …….. Year: ......

INFORMATION ABOUT DRIVER’S RESULTS

Year / Rally / Car / Class / Result / Finished cars
overall / in class
Inernat.
National
Others
DECLARATION OF INDEMNITY

We, below signed, declare that we enter the event on our own risk and will not carry any responsibility from any accidents, injuries or damages cause during the event to the rally organisers. We declare that we are familiar with FAS ACCR national regulations and Supplementary regulations and will follow instructions and rules of the event, as well as accept instructions and decisions of the Stewards and rally control.

AGREEMENT

We declare that all filled data are correct and that we accept above stated terms and conditions of the event.

ASN stamp * / Competitor’s signature / Driver’s signature / Co-driver’s signature

*) Can be equalled by Approving letter issued by the competitor’s ASN

Place: …………………………………….….. Date: ………………..

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