Canadian Association of Rallysport

Canadian Association of Rallysport
Performance Rally Registration Form/Formulaire d’inscritpion du rallye
Name of Event/Nom de l’événement
Rallye Défi 2016
Seed/
Classe
Championship/Championnat
National
(
(
(
(
(
Regional
National class/Classe nationale –
Regional class/ Classe régionale -
) Rally Pacific Motorsports
) Rally West
) RallySport Ontario
) Rally Sport Québec
) Atlantic Region
Expert
Expert
Novice
Novice
Entrant/Propriétaire
Name/Nom____________________________________________________ Phone/Tél (
)-
-
.
Address/Adresse _________________________________ _____________________________ Prov./State _______________
City/Ville _________________________________________________________________ Code ________________________
Driver/Pilote
Name/Nom____________________________________________________ Phone/Tél (
)__
Address/Adresse _________________________________ __________________________ Club
-
.
_____________________
City/Ville ____________________________________Prov./State_____________________ Code _______________________
Email __________________________________________________________________________________________________
Driver’s licence no./ N˚ de permis de conduire ______________________________________ Prov./State__________________
Competition licence no./N˚ de licence de rallye ______________ CARS – Nat
Reg
RA/NASA – Nat
Reg
FIA
Co-driver/Co-pilote
Name/Nom____________________________________________________ Phone/Tél (
)__
Address/Adresse _________________________________ __________________________ Club
-
.
_____________________
City/Ville ____________________________________Prov./State_____________________ Code _______________________
Email __________________________________________________________________________________________________
Driver’s licence no./ N˚ de permis de conduire ______________________________________ Prov./State__________________
Competition licence no./N˚ de licence de rallye ______________ CARS – Nat
Vehicle /Véhicules Class/Classe:
Open/Ouvert 4WD
Reg
RA/NASA – Nat
Prod 4WD
Reg
Open/Overt 2WD
FIA
Prod 2WD
Gr5
Make/Fabricant __________________________________________________________ Year/ Anné______________________
Model/Modêle ________________________________________ Colour/Coleur ______________________________________
Licenceplate no./N˚d’immatriculation ___________________________________ Prov./State ___________________________
Insurance Co. Cie d’ assurance ____________________________________ Policy no./N˚de police ________________________
Wavier ( on reverse must be signed/ La renoniciation (au verso) doit être signee)