Syrian Int. Hill Climb Entry Form 2009

‫بطولة سورية السابعة لسـباقات السـرعة و تسلق الهضبة ‪2009‬‬

‫سباق تسلق الهضبة الدولي السابع‬ ‫‪7 Syrian international hill climb‬‬ ‫‪10/7/2009‬‬ ‫‪th‬‬

‫نموذج طلب اشتراك‬ ‫‪ENTRY FORM‬‬

‫السائق‬ ‫اسم العائلة‬ ‫السم الول‬ ‫الجنسية‬ ‫العنوان‬

‫‪1. Driver 1‬‬‫‪Surname‬‬ ‫‪First name‬‬ ‫‪Nationality‬‬ ‫‪Addressee‬‬ ‫‪Tel.No‬‬

‫ه‬ ‫ا‬ ‫ت‬ ‫ف‬ ‫‪Fax No‬‬

‫فاكس‬ ‫‪Mobile No‬‬

‫ر‬

‫‪Competition license No‬‬ ‫‪Issued By‬‬

‫معلومات السيارة ‪2. Car Details 2-‬‬

Maker of Car Year of Manufacture

‫سسسسنة‬ ‫الصنع‬ Model

‫الموديسل‬ ‫الطراز‬/ Registration No Country of Registration

‫بلد‬ ‫التسجيل‬ Cubic Capacity

‫سسعة‬ ‫سس‬ ‫المحرك‬ Motor number

‫رقسسسم‬ ‫المحرك‬ Chassis number

‫رقسسسم‬ ‫الهيكل‬ Owner s name

‫اسسسسم‬ ‫المالك‬ 3.Entry Fees ( OFFICIAL USE ONLY) 3- ‫)رسوم الشتراك )تمل من قبل اللجنة المنظمة فقط‬ Amount 200$ ‫الرسوم‬ Sponsor Fees 100$ ‫رسم الراعي‬ Insurance fees 75$ ‫رسم التأمين‬ Date Paid ‫تاريخ الدفع‬ ‫رقم و تاريخ الوصل‬ Receipt No Date Received ‫تاريخ إستلم الطلب‬

Entry Form with Full Entry Fees should be submitted to ‫تسلم كل طلبات الشتراك مع الرسوم الكاملة إلى‬: Syrian Automobile Club ‫نادي السيارات السوري‬ Motor Sport Office ‫المكتب الرياضي‬ P.O Box: 3364 3364 :‫ب‬.‫ص‬ Tel: 00963-11-2323706 00963-11-2323706 :‫هاتف‬ Fax: 00963-11-2312785 00963-11-2312785 :‫فاكس‬ :[email protected] Email : ‫البريد اللكتروني‬ VALID WHEN SIGNED, DATED, AND FULL ENTRY FEES PAID ‫يعد هذا النموذج رسميا عند دفع الرسوم كاملة مع التوقيع‬ Entrants Signature ………………………………… Date Class

No

SEEDING INFORMATION Driver --------------------------------Car--------------------------------

Group/Class------------------

FIA Priority A

Yes / No

FIA Priority B

Yes / No

if yes year ------------------------

National Seed

Yes / No

Priority -------------------------

National Championship Winner? Yes / No ------------------

Event

Yes / No

if yes, Championship --------------------year ----------

Car

Group

O/A Position

Class position

No. of Finishers

Other

National

international

year

Previous FIA seed

DECLARATION OF INDEMNITY I have read and understood the regulations issued for this event and agree to be bound by them and by the international sporting code of the FIA. In consideration of the acceptance of my entry or of my being permitted to take part in this event, I agree to save harmless and keep indemnified, the Syrian Automobile Club and all sponsors together with such persons who are responsible for the organization of the event and the receptive officials, servants, representative, employees and agents from the all against actions, claims, costs expenses, and demands in respect of injury or death to myself and/or loss damage to my property howsoever caused arising out of or in connection with my entry or taking part in this event, notwithstanding that the same may have been contributed to or occasioned by the negligence of the said bodies their officials, employees, servants, representatives or agents .

ACKNOWLEDGEMENT AND 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 1st driver

Or letter from entrants ASN authorizing and approving the entry *

---------------------------DATE