START No.

E N T R Y F O R M

ENTRY REGISTRATION FORM: (mark with X) / ERT / PH / PH
JUN / Š
BiH / K
BiH / PSL / PSL
JUN

ERT – European rally Trophy, PH – Croatian Championnship (+junior), ŠBiH Bosnia and Herzegovina Championship (+cup) PSL – Nord Regue Championship (+junior)

COMPETITOR / FIRST DRIVER / CO-DRIVER
Competitor name
Surname
Name
Date of birth
Place of birth
Nationality (as licence)
Postal address
Passport number
Address for correspodence (1,2 or 3) / 1. / 2. / 3.
Telephone No (business)
Telephone No (private)
Mobile Telephone No
Fax No
E mail address
Competition licence No
Issuing ASN
Driving licence No
Country of issue
DETAILS OF THE CAR
Make / Registration No
Model / Engine capcity (ccm)
Year of manufacture / Chassis No
Group / Class / Engine No
Homologation No / Predominant colour
Country of registration / Technical passport No
TYPE OF ENTRY
Trade / Legal etc.
Private / Amateur
Organisers' proposed advertising accepted: / YES / NO
ENTRY FEES

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

ENTRY FEES / PRIVATE / AMATEUR / OTHERS / CLOSING DATE
Reduced rate / 500,00 € / 1000,00 € / 9. May 2017. – 24:00
Normal rate / 300,00 € / 600,00 € / 25. May 2017. – 24:00
SEEDING INFORMATION
TYPE OF ENTRY
Driver Name / Car / Class
Current FIA Priority / Yes / No / Previous FIA Priority / Year
Current National Seeded / Yes / No / Previous National Seeded / Year
Title any Shampionship won / Year
Year / Event / Car / Group / O/A Position / Class Position / No of Finishers
International
National
Other
DECLARATION OF INDEMNITY
The entrant, driver and co-driver jointly and severally acknowledge and agree the following:
1. To abide by and be bound by the codes and regulations of the 43th INA DELTA RALLY 2017, held under the International Sporting Code, the Sporting and Technical Regulations of the FIA, the Regulations of the relevant National Sporting Authority ( ASN ) and the Supplementary Regulations issued for the 43th INA DELTA RALLY 2017.
2. That motor sport is dangerous and accidents causing death, bodily damage, disability and property damage can and do happen and in consideration of the acceptance of this entry, we agree that neither the FIA, the relevant ASN, the organisers and/or promoters and their respective officers, servants, representatives and agents and any other parties shall be under any liability for our death, or any bodily injury, loss or damage which may be sustained or incurred by us as a result of participation in the 43th INA DELTA RALLY 2017, and to the fullest permitted by law agree to indemnity and hold harmless each of those parties.

ACKNOWLEDGEMENT AND AGREEMENT

By me 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 Competitor / Signature of Driver / Od Co-driver

* Or letter from the wntrant's ASN authorising and approving the entry

Date______E-mail address for entryes: