APPLICATION FOR 2017SARRA MEMBERSHIP G

(FULL CALENDAR YEAR)First suffix:N = Normal

(Red fields = official use only)B = Blind Series

Please complete this application form as well as the indemnity E = One Event

form on thereverse side (or attached separately to this form), O = Official

in full, or membershipapplication will not be processed Second suffix:F = Family Member

(only one per Normal Member )

I.D. Number………………………….……………First Name (In full):………………………………….....Surname……………..………………………………………

Date of Birth………………….Address…………………………………………………………………………………………………………Postal Code………………

Tel: (H)…(….……)…………………………………..Tel (W) …(….……)…………………..………………..Fax No…(…………)……………………………………..

Cell No. …………..…………………………………..e-mail…………………………………………………………………………………..………………………….……

Name of CarClub or SARRA Renewal:…………….……………….……….…………….. Currentmembership checked by:……..……………………….

The following information assists SARRA to obtain

funding from Motorsport South Africa Race: Sex: Male Female

CATEGORY OF MEMBERSHIP: NORMAL CAR CLUB BLIND SERIES ONE EVENT MARSHAL/OFFICIAL FAMILY

(Circle relevant category) MEMBERSHIP FEES: NORMAL R 250, CAR CLUB MEMBERS R 150,

BLIND SERIES R 50, ONE EVENT R 50,

MEMBERSHIP FEE RECEIVED: R ………………. BY ……………………….………….. MARSHALS & OFFICIALS R 50, FAMILY FREE (1 ONLY)

I, the applicant, hereby certify that:

i)I understand that should I, at the time of an event in which I intend taking part, be suffering from any condition/disability (whether permanent or temporary) which is likely to prejudicially affect control of my vehicle, I may not take part in the event concerned unless expressly permitted to do so by MSA following a declaration of my condition/disability. I further understand that, notwithstanding the issue of a licence to me by MSA it remains my responsibility not to participate in any event where a condition or disability suffered by me, may in any way affect my, or any other person’s safety.

ii)I declare that, to the best of my belief, I posses the standard of competence necessary to take part in any event entered, and that any vehicle entered will be suitable and roadworthy, having regard to the speeds which will be reached.

iii)I declare that any vehicle entered by me, will comply with all regulations and specifications pertaining to the event entered/category of motorsport concerned. I accept, subject to my rights of protest and appeal, that action will be taken against me, as the entrant and/or driver and/or rider, in accordance with the provisions of MSA’s regulations, if my vehicle is found not to comply with the relevant regulations and specifications.

iv)All information furnished in this application is true and correct. By signing this application I agree to abide by the Insurance Policy and Protocols.

v)I agree to allow a Doping Control/Alcohol Control Officer to examine me prior to, during or following a motor sporting event, meeting or competition. I further agree to allow a sample of my blood and/or urine to be taken for laboratory analysis by the Doping Control/Alcohol Control Officer concerned to determine the presence of alcohol or prohibited drugs as listed in the MSA Anti Doping Code, in accordance with the procedure for testing as prescribed in this Code. Should the analysis of the samples taken reveal the presence of alcohol or drugs or should I refuse to allow samples of blood and/or urine to be taken, I agree to MSA taking disciplinary action against me as envisaged in the MSA Anti Doping Code as prescribed by WADA.

Signature of applicant:………………………………………………………………….…….Date:……………………………………..

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2017-SARRA MEMBERSHIP Application Form (Full Year).doc2 January 2017