Patriot Stages 2009 - Entry Form

PLEASE PRINT IN BLOCK CAPITALS All Correspondence to: Driver Preferred Scrutineering Saturday:

Co-Driver. Sunday:

Entrant: Name Lic. No.

Note. Trade Entrant will not be credited without a Licence Number.

Crew: Driver

Co-Driver

Name Address

Post Code Telephone E mail Club Licence No. ASWMC Champ.

Yes Yes Yes Yes

H.O.E Champ. C.M.S.G Champ. BTRDA Champ.

No No No No

Reg No.

Yes Yes Yes Yes

Reg No Reg No. Reg No.

Mark as Applicable

Vehicle: Make: Colour

Reg No Reg No. Reg No. Reg No.

Mark as Applicable

Model: Reg. No.

Seeding Information: Date Event

No No No No

Cap c.c. Class

Status

Class Posn. Overall Posn.

Official Use only: Date Recd.

Reference

Ack. Date

Cheque No.

Seed Group

Comp. No.

DECLARATION OF INDEMNITY 'I declare that I have been given the opportunity to read the General Regulations of the Motor Sport Association and, if any, the Supplementary Regulations for this event and agree to be bound by them. I declare that I am physically fit to take part in the event and I 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. 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 a publicly adopted road, I agree to save harmless and keep indemnified The Motor Sports Association Ltd, 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 together with other Competitors and their respective Servants, Representatives and Agents, from and against all actions, claims, costs, expenses and demands in respect of Death of or injury to or Damage to the Property of myself, my Driver(s), Passenger(s), Mechanic(s) or associated personnel, arising out of or in connection with this entry or my taking part in this event.'

State your age if under 18 …………………….. '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.' Entrants Signature

: ......................……….

Age if under 18 : ...........……. Date: ...............

Drivers' Signature

: .....................……….

Age if under 18 : ............……. Date: ...............

Co-Drivers Signature

: ...................…………

Age if under 18 : ...........…….. Date: ...............

Important note if you are under 18 years of age: If an entrant/Driver/Co-Driver is under 18 years of age, this form must be countersigned by his/her parent/guardian/guarantor, whose name, address, relationship to the entrant must be given. Also under revised regulations, effective 1st January 2005 it will be necessary for the parent/guardian/guarantor or representative to be present at the meeting and a separate indemnification must be signed. If you are under 18 years of age, then please contact the organizers prior to submitting your entry. Name: ........................ Relationship : ................. Address: ...................... Signature : ................. ...................... Date : ................. ...................... Name: ........................ Relationship : ................. Address: ................….. Signature : ................. ...................… Date : …………. ..................… Drivers' next of kin :................………………………. Tel:.................……….. Co drivers next of kin

:................……………………….

Tel:.................………..

This entry form must be completed in every respect, including signing the indemnification and sent to the entry secretary together with all fees due. Cheques should be made payable to "CAERWENT RALLY". Entry fee

:

£205.00 -

£................

Forresters Membership : £10.00 -

£.................

SWAC Membership

£…………..

Total

:

: £ 7-00

£..................

Entry Secretary: Fiona Evans Woodend 15 Plough Lane Penperlleni Pontypool Monmouthshire NP4 0AL