Entrant information: To

Name
Organization
Address
Town
County
Postal Code
Phone
FAX
E-mail

Driver information:

*Name
*Address
*Town
*County
*Postal Code
Phone
Mobile
E-mail

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Driver Competition Licence Number:*

In the event of an accident or emergency please contact:

*

Phone Number (with code)*

Please enter the details of your rally car

Car Model:*

Cubic Capacity:* cc

Class Entered (see regs):*

Car Registration Number:*
 

 

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To be completed by Entrant

UNDERSTANDINGS, DECLARATIONS AND UNDERTAKING BY ENTRANTS INDEMNITIES

1.   ‘I declare that I have been given the opportunity to read the General Regulation 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 motorsport and agree to accept that risk.  Further, I understand that all persons having any connection with the promotion and/or conduct of the event are insured against loss or injury caused through their negligence’ 

2.   I declare that the use of the car hereby entered will be covered by insurance as required by the Road Traffic Act, N Ireland 1977, which is valid for such parts of the event as shall take place on the road as defined in the Act.

3.   I agree to maintain in good condition any Perpetual Trophies won by me, and to return them to the  Secretary, MADMC Ltd when requested to do so.

I the Entrant have read and agree with the above Understandings, Declarations and Undertakings:

Yes No

Date:
-- dd/mm/yy

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       To be completed by Driver

UNDERSTANDINGS, DECLARATIONS AND UNDERTAKING BY  DRIVERS  INDEMNITIES

1.   ‘I declare that I have been given the opportunity to read the General Regulation 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 motorsport and agree to accept that risk.  Further, I understand that all persons having any connection with the promotion and/or conduct of the event are insured against loss or injury caused through their negligence’ 

2.   I declare that the use of the car hereby entered will be covered by insurance as required by the Road Traffic Act, N Ireland 1977, which is valid for such parts of the event as shall take place on the road as defined in the Act.

3.   I agree to maintain in good condition any Perpetual Trophies won by me, and to return them to the  Secretary, MADMC Ltd when requested to do so.

I the Driver have read and agree with the above Understandings, Declarations and Undertakings:

Yes No

Date:
-- dd/mm/yy

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*Driver Declaration

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:

  Yes No

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Please indicate where you think you should be seeded:

0-10
11-20
21-30
31-40
41-50
51-60
61-70
71-90
91-110
111-130
Over 130

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Who is to receive the Final instructions?
    
             Driver:        Co-Driver:

 

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Any other Comments you wish to add:




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completed entry and medical forms.