ENTRY FORM

PLEASE PRINT IN BLOCK CAPITALS

All Correspondence to: Driver Co-Driver.
Preferred Scrutineering Saturday: 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 No Reg No. Yes No Reg No
H.O.E Champ. Yes No Reg No Yes No Reg No.
C.M.S.G Champ. Yes No Reg No. Yes No Reg No.
Mark as Applicable Mark as Applicable
Vehicle:
Make: Model: Cap c.c.
Colour Reg. No. Class

Seeding Information:
Date Event 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: £195.00 £................ Entry Secretary:

Fiona Evans
Forresters Membership: £10.00 £................. Woodend
15 Plough Lane
SWAC Membership: £ 7.00 £………….. Penperlleni
Pontypool
Monmouthshire
Total : £.................. NP4 0AL

This entry form was printed from the Caerwent Rallies Webpages.