QUBMC Official Entry Form

QUBMC Official Entry Form

Please complete using block capitals

1. Event Summer Lanes RallyDate 21st July 2012

DRIVER / NAVIGATOR
2. / Surname
First Name
Address
Post Code
Tel. No.
E-mail Address
Motor Club
Comp Licence No.

Do you want correspondence sent by e-mail? Yes / No

3. Details of Car

Make / Model / Reg No / Year / CC / Drive / Diff

4.Declaration of Indemnity

I have read the Supplementary Regulations issued for this event and agree to be bound by them and by the General Regulations of the Royal Automobile Club MSA Ltd. In consideration of the acceptance of this entry and of my being permitted to take part in this event, in respect of any parts of the event not held on a publicly adopted road, I agree to save harmless and keep indemnified the Royal Automobile Club MSA Ltd, such Person, Persons or Body as may be authorised by the Royal Automobile Club MSA Ltd to promote or organise this event and their respective Officials, Servants, Representatives and Agents together with other Competitors and their respective Servants, Representatives and Agents, from and against all actions, claims, costs, expenses and demands in respect of Death of or Injury to or Damage to the Property of myself, my Driver(s), Passenger(s), Mechanic(s) or associated Personnel, arising out of or in connection with this entry or my taking part in this event. I declare that the use of the vehicle hereby entered will be covered by insurance as required by the law which is valid for such part of this event which shall take place on roads as defined by the law.

5.Membership Declaration

As a duly elected member, the holder of a QUBMC membership card is entitled to take part in competitions promoted by QUBMC on signature of the following declarations: ‘I do not hold a valid competition licence issued by any national automotive club (other than a club within the European Union). I declare that I shall not drive in any part of a competition which takes place on the public highway unless I hold a valid motor vehicle driving licence (other than provisional). I am acquainted with and agree to be bound by, the general regulations of the MSA.’

6.Signatures:

Please sign below to confirm acceptance of the ‘Declaration of Indemnity’ contained in Section 4 and, if appropriate, the ‘Membership Declaration’ contained in Section 5.

Driver's Signature ……...... …………...... ……… Navigator’s Signature………………………………………………

Date……………… State your age if you are under 18 .…...... Date……………… State your age if you are under 18 ………..

If the driver or navigator is under 18 years of age this form must be countersigned by a Parent or Guardian.

Relationship to Driver ….....……………...... Relationship to Navigator ….....……………......

Print Name ……………………………………………….Print Name ………………………………..………………….

Signature ...... ……………………...... Signature ...... ……………………......

7. Details of Insurance Cover

To enable the organisers to assess each competitor's insurance arrangements the driver must mark ONE of the following options:

7.1 I have extended my own private motor insurance to cover my participation in this event ____

7.2 I have a valid NES letter in force with no loading ____

7.3 I declare that:

(i) I am over 21 years of age and have held a full driving licence for at least 6 months.

(ii) I have no more than 1 fault accident in the last 3 years

(iii) I have no convictions other than a maximum of 6 speeding points

(iv) I have no physical or mental disabilities

(v) I have no other material facts to disclose ____

7.4 I am unable to mark any of the above options ____

If you have marked option 7.1, 7.2 or 7.3 you are only required to complete the Lockton signing on form that will be available at the event sign on. If you have marked option 7.4 you must contact Lockton at least 7 days before the event to gain acceptance for insurance.

8. Fees Enclosed

I enclose fees as follows:

Entry Fee£ ......

Insurance£ ………….

Club Membership Driver£ ......

Club Membership Navigator£ ………….

Total£ ......