Cetus Stages Rally, Three Sisters,11th May 2013
Entry Form ~ Closing Date : 8th May 2013
It is the responsibility of the entrant to complete all sections of this form. The Secretary of the Meeting has the right to refuse any incomplete or incorrect entry. The entrant is responsible for sending this form with the appropriate entry fee to the Entry Secretary, who will acknowledge your entry by E mail.
Final Instructions, Entry list and results will only be published on the Motor Club web site:-
Driver Information
DRIVER : / First Name: / Surname:Address:
Postcode / email:
Tel (day): / Mobile:
Licence: / Type: / Over 17 / Under 17
Club(s): / (relevant clubs only please)
Next of Kin : / Relationship : / Tel :
Co-Driver Information
CO-DRIVER / First Name: / Surname:Address:
Postcode / email:
Tel (day): / Mobile:
Licence: / Type: / Over 17 / Under 17
Club(s): / (relevant clubs only please)
Next of Kin : / Relationship : / Tel :
Vehicle Details
Make: / Model / Type: / Year :
Reg No : / Colour :
Capacity: / cc / Class: / (A to E) / Turbo / Supercharged / Rotary (tick)
Fuel: / Petrol / Diesel / Other
Entrant Information (if applicable)
ENTRANT : / Name :Address:
Post Code: / Tel (day): / Mobile:
email: / Entrants Licence No:
Championships (tick as appropriate)
ANWCC. Stage Rally Championship / ANWCC. All-Rounders Championship / ANWCC. Ladies Stage Rally Championship
6R4.comThree Sisters Rally Challenge / SD34MSG Inter Club League / SD34MSG Stage Rally Championship
Recent Stage Rally Results
(for seeding purposes; no results = no seeded position)
Date / Event / Status / Class Position / Position O/A1
2
3
4
The Indemnity section on Page 2 must be completed
The form may be completed electronically but must be printed and signed.
Cetus Stages Rally, Three Sisters,11th May 2013
Entry Form ~ Closing Date : 8th May 2013
It is the responsibility of the entrant to complete all sections of this form. The Secretary of the Meeting has the right to refuse any incomplete or incorrect entry. The entrant is responsible for sending this form with the appropriate entry fee to the Entry Secretary, who will acknowledge your entry by posting you an acceptance card. Final Instructions, Entry list and results will only be published on the Motor Club web site:-
DRIVERS, CO-DRIVER AND ENTRANTS MUST COMPETE AND SIGN THE INDEMNIFICATION.
I declare that I have been given the opportunity to read the General Regulations of the Motor Sports Association and, if any, the Supplementary Regulations for this event and agree to be bound by them. I declare that I am physically and mentally fit to take part in the event and 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. State your age if under 18.
I declare that to the best of my belief the driver(s) possess(es) the standard of competence necessary for an event of the type to which this entry relates and that the vehicle entered is suitable and roadworthy for the event having regard to the course and the speeds which will be reached. 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.
DRIVER / CO-DRIVER / ENTRANT(if applicable)Signature: / ______ / ______ / ______
Parent / Guardian signature if under 18: / ______ / ______ / ______
Full Name:
PAYMENT(make cheques payable to Wigan DMC)
Entry Fee / £ / £155.00FOR OFFICIAL USE ONLY / Received / Acknowledged
Driver / Entrant / Paid / Completed / Novice / Class / Cheque No
Please return with payment to :
Adrian Spencer, Adgespeed Ltd. Unit 14, Thames Trading Centre, Woodrow Way, Irlam, Manchester, M44 6BP.
Mobile : 07960 964069 email :