The Cetus Stages, Three Sisters Race Circuit Wigan, Saturday 17th May 2014
Entry Form ~ Closing Date: 15th May 2014
It is the responsibility of the entrant to complete all sections of this form. The Secretary of the Meeting has the right to refuse any incomplete or incorrect entry. The entrant is responsible for sending this form with the appropriate entry fee to the Entry Secretary, who will acknowledge your entry by E mail.
Final Instructions, Entry list and results will only be published on the Motor Club web site:-
These forms may be completed electronically and must be printed and signed.
Driver Information
DRIVER : / First Name: / Surname:Address:
Postcode / email:
Tel (day): / Mobile:
Licence: / Type: / Over 18 / Under 18
Club(s): / (Relevant clubs only please).
Next of Kin : / Relationship : / Tel :
Driver’s Championships (tick as appropriate)
ANWCC. Stage Rally Championship / ANWCC. All-rounders Championship / ANWCC Ladies Stage Rally Championship6R4.com Three Sisters Rally Challenge / SD34 MSG Inter Club League / SD34 MSG Stage Rally Championship
Co-Driver Information
CO-DRIVER / First Name: / Surname:Address:
Postcode / email:
Tel (day): / Mobile:
Licence: / Type: / Over 18 / Under 18
Club: / (Relevant club only please).
Next of Kin : / Relationship : / Tel :
Co-Driver’s Championships (tick as appropriate)
ANWCC. Stage Rally Championship / ANWCC. All-rounders Championship / ANWCC Ladies Stage Rally Championship
6R4.com Three Sisters Rally Challenge / SD34 MSG Inter Club League / SD34 MSG Stage Rally Championship
Vehicle Details
Make : / Model / Type: / Year :
Reg No : / Colour :
Capacity: / c.c. / Class: / (A.B,C,D,E) / Turbo / Supercharged / Rotary (Tick).
Entrant Information (if applicable)
ENTRANT : / Name :Address:
Post Code: / Tel (day): / Mobile:
email: / Entrants Licence No:
Recent Stage Rally Results
(For seeding purposes; no results or car specified to be used on the rally = No seeded position).
Date / Event / Status / Class Position / Position O/A1
2
3
4
The Indemnity section on Page 2 must be completed and signed.
/ Wigan & District Motor ClubThe Cetus Stages, Three Sisters Race Circuit Wigan, Saturday 17th May 2014
Entry Form ~ Closing Date: 15th May 2014
It is the responsibility of the entrant to complete all sections of this form. The Secretary of the Meeting has the right to refuse any incomplete or incorrect entry. The entrant is responsible for sending this form with the appropriate entry fee to the Entry Secretary, who will acknowledge your entry by posting you an acceptance card. Final Instructions, Entry list and results will only be published on the Motor Club web site:-
DRIVERS, CO-DRIVER AND ENTRANTS MUST COMPETE AND SIGN THE INDEMNIFICATION.
D13.1 I declare that I have been given the opportunity to read the General Regulations of the Motor Sports Association and, if any, the Supplementary Regulations for this event and agree to be bound by them. I declare that I am physically and mentally fit to take part in the event and am competent to do so. I acknowledge that I understand the nature and type of the competition and the potential risk inherent with motor sport and agree to accept that risk. Further I understand that all persons having any connection with the promotion and/or organisation and/or conduct of the event are insured against loss or injury caused through their negligence. State your age if you under 18 .
D13.1.2 I understand that should I at the time of this event be suffering from any disability, whether permanent or temporary, which is likely to affect prejudicially my normal control of my vehicle, I may not take part unless I have declared such disability to the ASN which has following such declaration, issued a licence which permits me to do so.
D13.1.1.C I am the parent/Guardian/Guarantor of the driver; I understand that I shall have the right to be present during any procedure being carried out under the Supplementary Regulations issued for this event and the General Regulations of the MSA.
As the Parent/Guardian/Guarantor I confirm that I have acquainted myself with the General Regulations, I agree to pay any appropriate charges and fees pursuant to those Regulations, (to include any appendices thereto) and hereby agree to be bound by those Regulations and submit myself without reserve to the consequences resulting from those Regulations (and any subsequent alteration thereof). Further I agree to pay as liquidated damages any fines imposed upon me up to the maxima set out in Part 3 Appendix 1.
Note. Where the Parent/Guardian/Guarantor is not present there must be a representative who must produce a written and signed authorization to so act from the Parent/Guardian/Guarantor as appropriate.
DRIVER / CO-DRIVER / ENTRANT (if applicable)Name (of competitors)
Signature (of competitors) / ______/ ______/ ______
Full name of parent / guardian / guarantor if under 18 / N/A
Address of Parent / guardian / guarantor / N/A
Telephone number of parent / guardian / guarantor / N/A
Signature (of parent / guardian / guarantor) / ______/ ______/ ______
PAYMENT (Make cheques payable to Wigan & District Motor Club Rally Account)
Entry Fee / £ / £160.00FOR OFFICIAL USE ONLY / Received / Acknowledged
Driver / Entrant / Paid / Completed / Novice / Class / Cheque No
Please return with payment to:
Helen Fox, 41, Elgin Avenue, Ashton-in-Makerfield, Wigan, Lancs. WN4 ORH
Telephone : 01942 715653. email :
BACS transfers can be made to : Lloyds Bank. Sort Code: 30 17 48 Account number: 00145819
Account Name: Wigan & District Motor Club Rally Account