Sunday 1st July 2018

Entry Form

Complete the form and return it with your remittance (Cheques Payable to Clowne and District Motor Club) to:- John Hendley, Secretary to the Run,10 Gray Street, Clowne, Chesterfield, Derbyshire. S43 4RU (telephone number in case of queries 07528984109) or pay by bank transfer as indicated below and email your completed form to

Entries must be received before midnight on Friday the 15th June 2018

Entrant
Name
Address
Post Code
Email Address
Telephone Number / On event Mobile no
Driver
Name
Co-Driver
Name
Car
Make / Model
Year of Manufacture / Registration Number
Other information (Optional)
Payment
Entry to ClunRun 2018 (Includes 2 breakfasts and 2 buffet vouchers for finish) / £ 30:00
[ ] additional breakfast @ £2.50 each / £
[ ] additional cold buffets @ £5.00 each / £
Optional donation to South Yorkshire Air Ambulance / £
Total / £
Payment by Cheque/Cash [ ]Please IndicatePayment by Bank Transfer[ ]Please Indicate
If paying by Bank Transfer, please use the account details opposite. For your referenceplease use the registration number of the vehicle you have entered.
Entries will be acknowledged as they arrive but will not be accepted until payment has been received. / Bank / Nat West
Sort Code / 60-40-09
Account Name / Clowne and District Motor Club
Account Number / 41172639
Declaration of Indemnity
I have read the rules and regulations for the ClunRun Touring Assembly and agree to be bound by them. 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 the public highway, I agree to save harmless and keep indemnified the Clowne and District Motor Club, all landowners and venues, such person, persons or body as may be authorised by the Motor Sports Association Ltd to promote or organise this event and their respective officials, servants, representatives and agents from and against all actions, claims, costs and expenses and demands in respect of death or injury to or damage to property of myself and drivers, passengers, 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 this vehicle hereby entered will in all respects be legally permitted to be used on the public highway in in particular is covered by insurance as required by law, which is valid for such part of the event as shall take place on roads as defined by law.
Entrant Signature / Date
Driver Signature / Date

Notification of receipt of entry and distribution of final instructions will be made by email. If you do not have a valid email account, then please include 2 stamped addressed envelopes with your entry.

ACK / Accept / FI / RB / Paid to Treasurer/ Account Checked