ENTRY FROM

Stat number
I will compete for: (mark X) / Slovenian
Championship / Mitropa CUP / Yugo CUP
ENTRANT / DRIVER / CODRIVER
Competitor
Family name
Name
Date of birth / Junior 21 year YES/NO
Nationality
Number of passport / ID
Adress
City – post office
Country
Telephone no.
Mobil tel. no.
E mail
Competitor licence no.
Licence no. driver/co-driver
Issuing ASN
Driving licence no.
Country of issue
DETAILS OF THE CAR
Make / Country of registration
Model / Registration plates no.
Year of manufacture / ccm
Group/class / Body no.
Homolagation no. / Tech. Passport no.
Organisers proposed advertising accepted (mark): / YES / NO
Entry fee
Till 12.05.2017 - 24:00 / 400,00 €
Till 12.05.2017 – 24:00 / SUPPLEMETARY REGULATIONS / Appendix V and VI
Entry fee details: / bank name: / Nova Ljubljanska banka d.d.
IBAN: / SI56 02426 0010117343
SWIFT: / LJBASI2X
purpose: / Velenje – Name and Surname of the driver
SEEDING INFORMATION

Driver: ______

Car: ______Group/class: ______

FIA Priority YES / NO Previous FIA priority YES / NO Year ______

National priority YES / NE Previous national priority Year ______

National championship winner______Year ______

RESULTS / Year / Event / O/A
position / Class position
international
national

ACKNOWLEDGEMENT AND AGREEMENT

A competitor, driver and passenger agree and acknowledge by signing below, written on behalf of all
team members at the 32. Fuchs Rally Velenje 2017

1.  To accept the conditions of these Supplementary Regulations for the 32. Fuchs Rally Velenje 2017 to be held in accordance with the FIA International Sporting Code, General Regulations for the FIA Rally Championships, FIA Technical Regulations, Policies national branch associations AŠ2005 and we undertake that we will take fully into account.

2.  That the rally is dangerous and that accidents can result in death, injury, disability and property damage, and take responsibility for our performance at the 32. Fuchs Rally Velenje 2017 and waive any claim or claims versus FIA, the relevant ASN, the organizer, for any liability for death, personal injury, property damage incurred as a result of participation in the 32.Fuchs Rally Velenje 2017.

The signing also hereby declare that all information provided in the application is true and accurate.

ASN stamp / Signature of entrant / Signature driver / Signature co driver

Date ______

Send to (12.05.2017)

Avto moto turing klub Velenje,

Rudniška cesta 3, 3320 Velenje;

tel. +386 (0)3 897 1030 or +386 (0)41 558 320

Email: