MadMax National Rally 2018

3rd and 4th March 2018

CAR No.

ENTRANT / FIRST DRIVER / CO-DRIVER
Family Name
First Name
Date of Birth
Nationality
(as passport)
Postal Address
Passport Number/NRC No.
Address (1, 2 or 3) / 1 / 2 / 3
For correspondence
Telephone (Office)
Telephone (Home)
Mobile No.
Fax No.
Email Address
Competition Licence No
Issuing ASN
Driving Licence No.
Country of Issue
DETAILS OF THE CAR
Make / Registration No.
Model / C.C
Year of Manufacture / Body No.
Group/Class / Engine No.
Homologation No. / Predominant Colour
Country of Registration
Tech. Passport No.
Type of entry: / Trade/Legal etc / Private/Amateur
Organisers’ proposed advertising accepted: Yes / No

ENTRY FEES

(For this entry to be valid it must be accompanied by the appropriate entry fees, a receipt for the full amount paid to the entrants ASN, a bankers draft or details of a bank transfer etc.)

ENTRY FEES / COMMERCIAL / PRIVATE / CLOSING DATE
With Advertising / ZMK / ZMK 1200.00 / 28-02-2018
Without Advertising / ZMK / ZMK 2400.00 / 28-02-2018

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DECLARATION OF INDEMNITY

I have read and agree to be bound by the Supplementary Regulations for the MadMax National Rally 2018.

I agree that neither the MadMax National Rally 2018 nor the Zambia Motor Sports Association (ZMSA) nor the promoter, any official, guarantor and/or sponsor of any competition or the owner/s of the property on which the competition is held nor any government, provincial or municipal body and their representatives shall be liable under any circumstances for any damage done by any vehicle entered by or ridden in or attended upon by me in any competition or for any personal injury – fatal or otherwise – or loss of whatever whether caused during any practice run or while the said vehicle/s on any road or area forming part of the track or route or any deviation there from or any approach by whatever means such damage, injury or loss caused and even though the same may be contributed or caused by wilful act, neglect or default of any official agent, servant or representative for the MadMax National Rally 2018, ZMSA or any promoter, organiser, guarantor or sponsor of the competition or the owners of the property on which the competition is held or any government, provincial or municipal body.

I hereby indemnify the MadMax National Rally 2018, ZMSA, the promoter, any official, organiser, guarantor and sponsor of the competition and the owner/s of any property on which competition is held and any government, provincial or municipal body and their respective officials, agents servants and representatives against any legal liability for any damage or injury so done or sustained as aforesaid by myself or any other such persons as aforesaid. I further declare that I am aware of the risks, dangers and perils attendant upon motor car racing or rallying or other form of motoring competition, which I hereby assume.

Every driver and co-driver will be required to sign the following agreement:

I agree to allow a medical practitioner 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 medical practitioner concerned to determine the presence of alcohol or prohibited drugs as listed by the FIA and in accordance with the procedure for testing as prescribed by them. Should the analysis of the samples taken show any traces of alcohol or drugs, should I refuse to allow samples of my blood and/or urine to be taken, I agree to my suspension for 12 months from participating in all form of motor sport run under the control of ZMSA, without a court enquiry or tribunal being conducted by ZMSA, and without being allowed recourse through appeal against the 12 months suspension imposed for using alcohol or drugs or refusing to allow samples of urine and/or blood to be taken as per this agreement.

By my signature I declare that all the information contained on the entry form is correct and that I acknowledge and agree in full to the terms and conditions of the above indemnity and that I accept all the terms and conditions relating to my participation in this event.

ASN STAMP * / Signature of Entrant / Signature of / Signature of
1st Driver / Co-Driver

*Or letter from the entrant’s ASN authorising and approving the entry Date______

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