Rally Guide - Appendix V - Rally Of Lebanon Official Website

Transcription

RALLY GUIDE – APPENDIX V (FORMS)
APPENDIX V
FORMS
6, 7 & 8 September 2013
Page 1
RALLY GUIDE – APPENDIX V (FORMS)
This page has been left blank intentionally
Page 2
6, 7 & 8 September 2013
36 Rally of Lebanon
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September 6th, 7th and 8th 2013
Seeding Information
Information du Classement
Competition No. / No. de compétition
Entrant / Concurrent:
______________________________________________________
Make and model / Marque et modèle:
Colour / Couleur:
___________________________________________
__________________________________________________________
Registration No. / No. d’immatriculation:
_______________________________________
Telephone / Téléphone: _______________
E-mail / E-mail:
Fax / Facsimile: _____________________
___________________________________________________________
FIA Priority / Priorité de la FIA
YES / OUI 
NO / NON 
National Seed / Pilote Prioritaire Nationale
YES / OUI 
NO / NON 
Previous FIA seed / Priorité Précédente de la FIA
YES / OUI 
NO / NON 
If Yes, Year / Année _________
YES / OUI 
National Championship Winner
NO / NON 
Gagnant d’une Championnat Nationale
If Yes, Championship
Si oui, championnat
Event / Evénement
Année ______
Car /
Voiture
Class
Classe
Overall Position
Position générale
Class Position
Position par classe
Other
National
International
Year
Année
Year
Signatures / Signatures
Date / Date: __________________
1
No. of Finishers
Nos. des arrivants
This page has been left blank intentionally 36 Rally of Lebanon
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Promotion Classification Entry Form
Demande d’engagement du Classement Promotion
______________________________________________________
Make and model / Marque et modèle:
Colour / Couleur:
___________________________________________
__________________________________________________________
Registration No. / No. d’immatriculation:
_______________________________________
Telephone / Téléphone: _______________
E-mail / E-mail:
Fax / Facsimile: _____________________
___________________________________________________________
With reference to the supplementary regulations of the 36 Rally of Lebanon:
4.4
There will be a PROMOTION classification for the competitors with the following conditions:
a) To hold the Lebanese nationality and competition licence.
b) Not to be F.I.A. priority drivers
c) Not to be a Lebanese A.S.N. priority driver
d) The car must be the property of one of the crew members and not the property of any dealer or
manufacturer.
e) Have not been classified among the first 3 during the past two years at the Rally of Lebanon.
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A list of PROMOTION classification will be issued at the same time as the starting list.
Suivant le Règlement particulier du 36 Rally of Lebanon:
4.4
Il sera établi un classement PROMOTION réservé aux équipages remplissant les conditions suivantes:
a) Titulaire de nationalité libanaise et détenant la licence sportive.
b) Ne pas être pilote prioritaire F.I.A.
c) Ne pas être un pilote prioritaire de l’ASN libanaise.
d) Le véhicule engagé devra être la propriété de l’un des membres de l’équipage et ne pas être la
propriété d’un constructeur ou d’un importateur de voiture.
e) Ne jamais avoir été classé parmi les trois premiers du Rally of Lebanon durant les deux
dernières années.
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Une liste des pilotes candidats au classement PROMOTION sera publiée avec la liste de départ.
I the undersigned hereby declare that I have been acquainted with the abovementioned article
and in accordance with the required conditions.
Je soussigné déclare avoir pris connaissance de l’article susmentionné, de même être conforme
aux conditions requises.
Date / Date: __________________
1
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Reconnaissance car registration
Inscription de la voiture de reconnaissance
Entrant / Concurrent: _____________________________________________
1st driver / 1er pilote:: _____________________________________________________
Accommodation / Accommodation: ___________________________________________
Telephone (Mobile) / Téléphone (Portable): ____________________________________
Reconnaissance car / Voiture de Reconnaissance:
Make and model / Marque et Modèle: ______________________________________________
Registration No. / No. d’immatriculation : ____________________________________________
Colour / Couleur: _____________________________________________________________
Owned by / Propriété de: ______________________________________________________
Insured by / Assuré par: ______________________________________________________
Reconnaissance is PROHIBITED from the publication of the itinerary to 2 days prior to the
administrative checks and scrutineering.
Please fill in this form and send it to the rally secretariat on Friday, August 30th, 2013 at the latest.
Les reconnaissances NE SERONT PAS AUTORISEE a partir de la date de publication de l’itinéraire et
jusqu’aux 2 jours précédents les vérifications administratives et techniques.
Prière remplir cette forme et l’envoyer au secrétariat du rallye au plus tard le Vendredi 30 Aout 2013.
DECLARATION OF INDEMNITY
My participation in the Reconnaissance of the 36th Rally of Lebanon is at my own risk and I will not hold
the Organisers, its Officials, the FIA as well as the ATCL (Automobile and Touring Club of Lebanon)
responsible for any accidents, injuries etc during the reconnaissance. I declare that we, (entrant, crew),
as well as our reconnaissance car, are insured for personal injuries and for civil liabilities towards third
parties. We also declare to have full knowledge of the rules and regulations issued by the FIA and the
ATCL covering and governing motor racing in all its aspects. I guarantee to respect all such rules and
regulations, without exception.
DECLARATION D'INDEMNITE
Ma participation à la reconnaissance du 36th Rally of Lebanon serait à mon entière responsabilité. Aucun
des organisateurs, officiels, la FIA et l'ATCL (automobile et Touring Club du Liban) ne sera tenu
responsable en cas d’accident, de dommage/[blessure] etc. pendant la reconnaissance.. Je déclare que
nous, (concurrent, équipage), aussi bien que notre véhicule de reconnaissance, sont assurés
physiquement (accident - atteinte physique) ainsi qu’en matière de responsabilité civile contre tiers.
Nous déclarons également avoir pris connaissance de tous les règlements publiés de la FIA et de l'ATCL
régissant le sport automobile dans tous ses aspects. Je m’engage à respecter toutes les
réglementations sans réserve.
ACKNOWLEDGEMENT AND AGREEMENT
By my signature, I hereby declare that all the information contained in this form and to the best of
my/our knowledge and belief are true and correct in every particular, and that I acknowledge and agree
in full to the terms and conditions of the above indemnity. I accept all the terms and conditions relating
to my participation in the reconnaissance of this event.
AVIS ET ACCORD
Je confirme par ma signature l’authenticité de toutes les informations remplies dans ce format, ainsi que
mon accord sur tous les termes et conditions d’indemnité tel que mentionnés. De même, je confirme
accepter toutes les conditions de participation aux “reconnaissances” de cet événement.
Date / Date: __________________
36 Rally of Lebanon
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Additional materials order form
Demande de matériel supplémentaire
____________________________
1st driver / 1er pilote:
____________________________
For any additional materials please fill in this form and send it on Friday August 30 , 2013 at the latest to:
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P.O. Box 115 - Jounieh / Lebanon
Tel.: +961-9-640220 / 640567 / 932020
Fax: +961-9-640579 / 934662
e-mail: [email protected]
web site: www.rallyoflebanon.com
Starting Tuesday September 3 2013, the materials can be collected from the Rally Secretariat, at the Rally
Office.
You can pay the materials with cash or by travellers’ cheques.
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Pour avoir du matériel supplémentaire, prière remplir cette forme et l’envoyer au plus tard le Vendredi 30
Aout 2013 à l’adresse suivante :
Tel.: +961-9-640220 / 640567 / 932020
Fax: +961-9-640579 / 934662
e-mail: [email protected]
web site: www.rallyoflebanon.com
A partir du Mardi 3 Septembre 2013 vous pouvez retirer le matériel demande auprès du Secrétariat du
Rallye, au bureau du Rallye.
Vous pouvez payer en espèces ou en travellers’ chèques.
ITEM / ARTICLE
QUANTITY / QUANTITE
UNIT PRICE
PRIX UNITAIRE
Service plates
50.00 U.S. $
Auxiliary plates
50.00 U.S. $
Reconnaissance Plates
35.00 U.S. $
Road books
75.00 U.S. $
Results CD
TOTAL PRICE
PRIX TOTAL
10.00 U.S.$
TOTAL AMOUNT
TOTAL
Date / Date: __________________
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Service crew / Vehicles registration
Equipage d’Assistance / Inscription des véhicules
1st driver / 1er pilote:
_____________________________________
_____________________________________
Service Team Manager :
_____________________________________
Dep. Service Team Manager :
_____________________________________
Vehicles gaining access to the Service Parks must display their special plate on the windscreen.
Les véhicules accédants aux Parc d’Assistance devront apposer leur plaque sur le pare-brise.
Vehicle 1 / Véhicule 1
Make / Marque
Model / Modèle
Color / Couleur
Registration No. / No. d’immatriculation
Names of Service Crew /
Noms d'Équipage de Service
1
2
3
4
Vehicle 2 / Véhicule 2
Make / Marque
Model / Modèle
Color / Couleur
1
2
3
4
Auxiliary Vehicle /
Make / Marque
Véhicule Auxiliaire
Model / Modèle
Color / Couleur
1
2
3
4
2013 FIA Regional Rally Championships Sporting Regulations, Article 16.3:
The service vehicles and cars used for the purpose of reconnaissance, even those bearing special plates issued by the organisers, are not covered by the insurance policy of the rally.
Règlement Sportif des Championnats Régionaux des Rallyes de la FIA 2013, Article 16.3:
Les véhicules d'assistance et les véhicules utilisés aux fins des reconnaissances, même porteurs de plaques spécifiques délivrées par l'organisateur, ne sont pas couverts par la police 'assurance
du rallye.
Date / Date: __________________
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Request for consecutive service area
Demande de zone d'assistance consécutive
I/We the undersigned hereby declare that I/we use the same Service Team and wish a consecutive service area in the service park.
Je/Nous le(s) soussigné(s) déclare(ons) que je/nous utilise(ons) le même équipe d’assistance et souhaite(ons) avoir une zone d’assistance
consécutive dans le parc d’assistance.
...............................................................................
...............................................................................
...............................................................................
Signed by (please tick)
Signé par
(Sélectionner s.v.p.)
Entrant
Concurrent
Team Manager
Directeur d’Equipe
CAR No
CAR No
CAR No
1st Driver
Co-driver
1er Pilote
Coéquipier
If this form has been prepared by the Entrant or the Team Manager, please specify the concerned driver.
Si le présent document est préparé par le concurrent ou le directeur d’équipe, prière spécifier le nom du pilote concerné.
............................................................................................................................................................
Name / Nom:
…………….............................................................................................................................................
Telephone / Téléphone:
……………...... Fax / Facsimile: ……….…..................Mobile / Portable: ……….…...................
Car No. will be completed by the organisers.
Le numéro de la voiture sera complété par les organisateurs.
Please fill in this form and send it, on Friday August 30th, 2013 at the latest, to the Rally Secretariat:
The Automobile and Touring Club of Lebanon
National Sporting Committee / Rally of Lebanon
Tel.: +961-9-640220 / 640567 / 932020
Fax: +961-9-640579 / 934662
e-mail: [email protected]; web site: www.rallyoflebanon.com
Prière remplir cette forme et l’envoyer au secrétariat du rallye au plus tard le Vendredi 30 Aout 2013.
Date / Date: __________________
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Fuel Purchase Form
Contact Details
Entrant:
1st Driver:
Co-Driver:
___________________________________________________
___________________________________________________
___________________________________________________
Telephone:
___________________________________________________
Mobile:
___________________________________________________
Fax:
___________________________________________________
E-mail:
___________________________________________________
Please tick to specify fuel type
Description
Cost (VAT incl.)
ELF TURBO EVO
(50 litre barrels)
U.S. $ 7.70/litre
TOTAL EFFIMAX 98 octane
current price of the
market at delivery time
Total Litres
Total Amount
Closing date for ordering fuel: Friday August 16th, 2013.
After deadline we cannot guarantee additional orders.
Please note that payment must be received in full before Friday August 23rd, 2013
either in cash or by means of bank transfer.
Payments can be remitted to the supplier’s bank account:
Account owner:
TOTAL Liban
Bank:
Bank Audi
Bank address:
Centre SOFIL, Ashrafieh Branch
IBAN:
LB86 0056 0002 0206 7421 0020 0936
Devise:
US Dollars
SWIFT CODE:
AUDBLBBX
With reference to the supplementary regulations of the 36th Rally of Lebanon:
8.1.3
Fuel dispense
The fuel will be dispensed to the competitor or his representative (duly assigned in writing) at the
refuelling zone - adjacent to the service park - subject to presenting the voucher given by “TOTAL Liban”
and in compliance with the schedule filled on the Fuel Purchase Order and mutually agreed upon
between “TOTAL Liban” and the purchaser.
It is the competitors’ responsibility to fill the appropriate form given by TOTAL Liban regarding the
quantity to be dispensed at each of the refuelling zones in the rally.
Litres to
dispense
Description
Remarks
Pre-Event / Monday 02/09/2013
For Leg 1 / Section 2
Friday 06/09/2013
Refuelling Zone (SP)
Saturday 07/09/2013
Sunday 08/09/2013
Sunday 08/09/2013
Remote Refuel
Remote Refuel
Remote Refuel
Remote Refuel
ACKNOWLEDGEMENT AND AGREEMENT
By my signature, I the undersigned, hereby declare that all the information contained in this
form and to the best of my/our knowledge and belief are true and correct and I have been
acquainted and in accordance with the required rules and conditions set in the Supplementary
Regulations of the 36th Rally of Lebanon, and in signing this form I agree to the abovementioned
charges and stipulations under any reserve.
N.B.
Date / Date: __________________
Please fill in this form and send it to “TOTAL Liban” on Friday August 16th, 2013 at the
latest.
36 Rally of Lebanon
th
2-Way Radio Licence Application for Short Term Use
Entrant:
1st Driver:
Co-Driver:
___________________________________________________
___________________________________________________
___________________________________________________
Telephone:
___________________________________________________
Fax:
___________________________________________________
E-mail:
___________________________________________________
No. of base station(s)
Type
Serial No.(s)
No. of mobile station(s)
Type
Serial No.(s)
No. of portable station(s)
Type
Serial No.(s)
Period of use
from:
____________
to:
____________
No fees will be incurred in exchange for the radio licence.
Any crew found to be in breach of this rule will be liable to further proceedings. However, if their
frequencies interfere with the organisation network, sanctions could lead to exclusion.
Please fill in this form and send it to the rally secretariat on Friday August 30th, 2013 at the latest.
____________________
Date / Date: __________________
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On-Board Cameras/ In-Car Videos Request Form
Entrant:
1st Driver:
Co-Driver:
___________________________________________________
___________________________________________________
___________________________________________________
Telephone:
___________________________________________________
Fax:
___________________________________________________
E-mail:
___________________________________________________
DETAILS OF THE VEHICLE
Make
Registration No
Model
Cubic capacity
Year of manufacturing
Chassis No
Group & Class
Engine No.
FIA homologation No
Predominant colour
Country of registration
Technical passport No.
With reference to the supplementary regulations of the 36th Rally of Lebanon:
11.4 - Scrutineering requirements:
 In accordance with Appendix A, Article 60, of the National Sporting Code, all Competitors, teams and
entrants who wish to carry on-board cameras, in-car videos and/or film cameras must have the prior
agreement of the Organisers beforehand. However, it is MANDATORY to provide the Organisers
and/or the Clerk of the Course with a copy of the recordings upon requisition.
Authorised cameras will be identified by an adhesive decal and must be mounted in the car at the time of
scrutineering.
The On-Board Camera Application Form can be collected from the Rally Secretariat or downloaded from
the 35th Rally of Lebanon official website. This form should be filled and sent to the Rally Secretariat by
Friday August 30th, 2013 at the latest.
Failing to observe this rule will be subject to a penalty at the discretion of the Stewards of the
Meeting.
I the undersigned hereby declare that I have been acquainted with the abovementioned article
and in accordance with the required stipulations under any reserve.
Date / Date: __________________
This page has been left blank intentionally 36 h Rally
ll off Lebanon
b
36th
MIDDLE EAST RALLY CHAMPIONSHIP
6-8,, September
2013
p
No
CAR No.
RALLY
Manufacturer
Standard Number
Standard Number
LEBANON
Model
Type
Jet
Helmet
H l t
Full
F ll
FHR Device
FHR Device
Driver
Overall
8856 2000
8856‐2000
Gloves
8856 2000
8856‐2000
Balaclava
8856‐2000
8856
2000
Top Underwear
Top Underwear
8856
2000
8856‐2000
Boots
8856‐2000
8856
2000
Socks
8856‐2000
Pants
8856‐2000
M
Manufucturer
f t
St d d N b
Standard Number
M d l
Model
T
Type
Jet
Helmet
Full
FHR Device
CoDriver
Overall
8856‐2000
Balaclava
8856‐2000
Top Underwear
8856‐2000
B
Boots
8856 2000
8856‐2000
S k
Socks
8856 2000
8856‐2000
Pants
8856 2000
8856‐2000
Name Signature
(Team
(Team
R
t ti )
Representative)
R
t ti )
Representative)
th
Media Accreditation Form
Forme d'Accréditation des Médias
PROFESSIONAL INFORMATION - INFORMATION PROFESSIONNELLE
Please mark the symbol ( □ ) where appropriate - Prière de marquer le symbole ( □ ) ou nécessaire
Media:
Media:
 Newspaper
 Magazine
Journal
Magazine
 Press Agency
 Radio
Agence de Presse
Radio
 T.V.
 Other
Télé
Autres
P.O. Box:
Address:
Adresse:
Boite Postale:
City:
Cité:
Country:
Pays:
Phone:
Fax:
E-mail:
E-mail:
Website:
Téléphone:
Fac-simile:
Site Web:
PERSONAL INFORMATION - INFORMATION PERSONNELLE
Surname and Name:
Nom et Prénom:
 Journalist
 Photographer
Male
 Female
Journaliste
Masculin
Photographe
 Other
Autres
________________________________
(Please Specify / Prière de Préciser)
Féminin
P.O. Box:
Address:
Adresse:
Boite Postale:
City:
Cité:
Country:
Pays:
Phone:
Téléphone:
E-mail:
E-mail:
Nationality:
Nationalité:
Permis FIA 2012
FIA 2012 Pass Holder
 YES / OUI
 NO / NON
If accreditation is deemed for more personnel, kindly fill the information on the back.
Si l'accréditation est nécessaire pour plus de personnes, prière de remplir l’information au verso de ce formulaire.
The Automobile and Touring Club of Lebanon
P.O. Box: 115 - Jounieh / Lebanon Tel: + 961 9 640220 / 640567 / 932020 Fax: + 961 9 640579 / 934662
E-mail: [email protected] - Official website: www.rallyoflebanon.com
1
Surname:
First Name:
Nom:
Prénom:
E-mail:
E-mail:
Phone:
Profession:
Nationality:
Nationalité:
Profession :
Téléphone:
2
Surname:
First Name:
Nom:
Prénom:
E-mail:
E-mail:
Phone:
Profession:
Nationality:
Nationalité:
Profession :
Téléphone:
3
Surname:
First Name:
Nom:
Prénom:
E-mail:
E-mail:
Phone:
Profession:
Nationality:
Nationalité:
Profession :
Téléphone:
4
Surname:
First Name:
Nom:
Prénom:
E-mail:
E-mail:
Phone:
Profession:
Nationality:
Nationalité:
Profession :
Téléphone:
5
Surname:
First Name:
Nom:
Prénom:
E-mail:
E-mail:
Phone:
Profession:
Nationality:
Nationalité:
Profession :
Téléphone:
6
Surname:
First Name:
Nom:
Prénom:
E-mail:
E-mail:
Phone:
Profession:
Nationality:
Nationalité:
Profession :
Téléphone:

Rally Guide - Appendix V - Rally Of Lebanon Official Website

Transcription

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