MABLETHORPE & DISTRICT MOTOR CLUB
THE BILL CAMMACK TROPHY RALLY 2006
ENTRY FORM

Driver

Licence No.

Name

Address

Tel. No.

Post Code

Club

Person to be informed in case of accident :
Name…………………………………………………………………………………………………………….
Address…………………………………………………………………………………………………………
Tel. No………………………………….Relationship…………………………………………………………

Co-Driver

Licence No.

Name

Address

Club

Tel. No.

Post Code

Person to be informed in case of accident :
Name…………………………………………………………………………………………………………
Address……………………………………………………………………………………………………...
Tel. No………………………………Relationship………………………………………………………...

Entrant

Licence No.

Name

Address

Tel. No

Post Code

Email address

Email address

Mobile phone number

Mobile phone number

PLEASE COMPLETE THE ENCLOSED LABELS WITH YOUR NAME AND ADDRESS

Ref. No.

Computer

Payment details

Acknowledged

Received

All correspondence to ENTRANT DRIVER CO-DRIVER

For Organisers’ use only :

Entry Fee : £170:00
Membership of MDMC (if required) £ 12:00

Class

O/A

Event

Year

Seeding Information (result of best 5 events in last 2 years)_

Championships ANEMMC (Please indicate)

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4 x 4

Reg. No. :

Model :

Class :

Turbo :

Cubic capacity:

Colour :

Make :

Car Details

Competitor No.

MABLETHORPE & DISTRICT MOTOR CLUB
BILL CAMMACK TROPHY RALLY
25th . February 2006
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 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.
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’s signature………………………………………………………………………
Co-driver’s
Signature……………………………………………………………………….
Any indemnity and/or declaration which is signed by a person under the age of 18 years must be countersigned by that person’s parent or guardian whose full name and address must be supplied.
This entry is made with my consent :
Signature…………………………………………………………………..
Name (in capitals)……………………………………………………….
Address……………………………………………………………………
……………………………………………………Post Code……………
(……………………………………………………………………………
Relationship………………………………………………………………..