rallye de nouvelle caledonie 2006 entry form - rallye

RALLYE DE NOUVELLE CALEDONIE
2006
ENTRY FORM
FORM OF INDIVIDUAL ENGAGEMENT - FORMULAIRE D'ENGAGEMENT INDIVIDUEL
* Write in readable capital letters - Ecrivez en lettres capitales lisibles
ENTRANT - ENGAGE
DRIVER - PILOTE
CO-DRIVER - CO-PILOTE
Name
Nom de l'équipe
Family Name
Nom de Famille
First Name
Prénom
Date of Birth
Date de Naissance
Nationality (Passport)
Nationalité (Passeport)
Reaction or allergy to any drug
Contre indication médicale
Postal Adress
Adresse Postale
Passport Number
Numéro de Passeport
Adress for correspondance
Adresse Courrier
Business Phone
Téléphone Professionnel
Private Phone
Téléphone Privé
Mobile Phone
Téléphone Mobile
Fax
Fax
Email Adress
Adresse Email
Competition Licence Number
Numéro de License de Compétition
Issuing ASN
ASN d'appartenance
Drivers Licence Number
Numéro de Permis de Conduire
Country of Issue
Pays de délivrance
ENTRY FEES - DROITS D'INSCRIPTION
OPTIONAL ADVERTISING
AMOUNT
CLOSING DATE
PUBLICITE RACHETABLE
MONTANT
DATE DE FERMETURE
International & Manufacturer entries
YES
150 000 XPF
Friday 24 March 2006
International & Manufacturiers
NO
300 000 XPF
Friday 24 March 2006
New Caledonian Privateer entries
YES
80 000 XPF
Friday 24 March 2006
Concurrents Néo Calédoniens
NO
160 000 XPF
Friday 24 March 2006
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RALLYE DE NOUVELLE CALEDONIE
2006
ENTRY FORM
SEEDING INFORMATION - INFORMATION SUR LES PILOTES PRIORITAIRES
* Write in readable capital letters - Ecrivez en lettres capitales lisibles
FIA PRIORITY
First Driver
Premier Pilote
FIA Priority A (YES or NO)
Car
Pilote Prioritaire FIA A (OUI ou NON)
Voiture
FIA Priority B (YES or NO)
Group / Class
Pilote Prioritaire FIA B (OUI ou NON)
Groupe / Classe
PREVIOUS FIA SEED
NATIONAL CHAMPIONSHIP - CHAMPIONNAT NATIONAL
Previous FIA seed (YES or NO)
National Championship winner ? (YES or NO)
Pilote Prioritaire FIA par le passé (OUI ou NON)
Vainqueur d'un championat national ? (OUI ou NON)
If yes, which year ?
If yes, which Championship and which year ?
Si oui, en quelle année ?
Si oui, quel Championat et quelle année ?
FFSA PRIORITY
ADDITIONAL INFORMATION - INFORMATION ADDITIONNELLE
FFSA Priority A (YES or NO)
Pilote Prioritaire FSSA A (OUI ou NON)
FFSA Priority B (YES or NO)
Pilote Prioritaire FFSA B (OUI ou NON)
EVENT
CAR
GROUP
GENERAL
POSITION
CLASS
POSITION
NUMBER OF
FINISHERS
ANNEE
EPREUVE
VOITURE
GROUPE
CLASSEMENT
GENERAL
POSITION
DANS LA
CLASSE
NOMBRE DE
CLASSES A
L'ARRIVEE
OTHER - AUTRE
NATIONAL
INTERNATIONAL
YEAR
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RALLYE DE NOUVELLE CALEDONIE
2006
ENTRY FORM
DISCLAIMER EXCLUSION OF LIABILITY, RELEASE AND ASSUMPTION OF RISK ENTRANTS AND/OR COMPETING CREWS IN RALLIES
For entrants
I/We being the entrant/s of the vehicle described on this Entry Form wish to enter that vehicle for the above event.
For entrants and competing crew
I/We being the entrant/s and/or driver and/or co-driver and/or navigator, certify that the particulars on this form are true and correct in
every particular, to the best of my/our knowledge and belief.
I/We declare that I/we have read and understood the Supplementary Regulations issued for the event, and agree to be bound by them
and the provisions of the National Competition Rules of the Comité Organisateur du Rallye de Nouvelle Calédonie (“CORNC”).
In exchange for being able to attend or participate in the event (including entering the event), I agree:
• to release CORNC and Association Sportive Automobile de Nouvelle Calédonie (“ASANC”), promoters, sponsor
organisations, land owners and lessees, organisers of the event, their respective servants, officials, representatives and
agents (collectively, the "Associated Entities") from all liability for my death, personal injury (including burns), psychological
trauma, loss or damage (including property damage) ("harm") howsoever arising from my participation in or attendance at the
event, except to the extent prohibited by law;
• that CORNC and the Associated Entities do not make any warranty, implied or express, that the event services will be
provided with due care and skill or that any materials provided in connection with the services will be fit for the purpose for
which they are supplied; and
• to attend or participate in the event at my own risk.
I/we acknowledge that:
• the risks associated with attending or participating in the event include the risk that I may suffer harm as a result of:
• motor vehicles (or parts of them) colliding with other motor vehicles, persons or property;
• acts of violence and other harmful acts (whether intentional or inadvertent) committed by persons attending or
participating in the event; and
• the failure or unsuitability of facilities (including grand-stands, fences and guard rails) to ensure the safety of
persons or property at the event.
• motor sport is dangerous and that accidents causing harm can and do happen and may happen to me.
• the route instructions should not be relied upon exclusively in estimating the degree of severity of any hazard which might be
encountered, or the manner in which any section of the road is driven, whether shown in the route instructions or not, and that
I/We have been advised to exercise caution in following these route instructions.
I accept the conditions of, and acknowledge the risks arising from, attending or participating in the event and being provided with the
event services by CORNC and the Associated Entities.
I understand that this disclaimer is not intended to exclude any valid claim I may have under the CORNC Personal Insurance Scheme.
I/we acknowledge that my/our personal information will be processed in accordance with the CORNC privacy policy which is available
from the website www.rallye-nc.net and where I/we suffer from any injury, sickness or death during the Event, I/we consent to the
release by health services of my/our personal health information to an authorised representative of CORNC or the Event who may use it
in the preparation and release within and outside New Caledonia of accident or incident information and reports to interested parties for
the purposes of accident investigation, accident prevention and safety activities, news services including broadcast services, or for the
purposes of processing insurance claims.
The regulation in New Caledonia requires that all vehicles be assured.
All the vehicles imported of the outside of New Caledonia will have to be temporarily assured for the duration their stay in New Caledonia by an
insurance covering the thirds at least. (Vehicle of rally, assistance and auxiliary)
For this entry to be valid it must be a accompanied by the appropriate fees, a receipt for the full amount paid to the entrants ASN, a bankers draft or
details of a bank transfer, etc.
Pour que ce formulaire d'engagement soit valable, il doit être acompagné des droits d'engagements appropriés, d'un recu pour la somme totale payée
aux ASN des engagés, d'une traite bancaire, de détails concernant un transfert bancaire, etc.
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RALLYE DE NOUVELLE CALEDONIE
2006
ENTRY FORM
DETAILS OF THE CAR - DETAILS DE LA VOITURE
* Write in readable capital letters - Ecrivez en lettres capitales lisibles
Make
Registration Number
Marque
Numéro d'Immatriculation
Model
C.C
Modèle
Cm3
Year of manufacture
Body Number
Année de fabrication
Numéro de chassis
Group / Class
Engine Number
Groupe / Classe
Numéro de moteur
Homologation Number
Predominant colour
Numéro d'homologation
Couleur prédominante
Country of registration
Tech. Passport Number
Pays d'enregistrement
Numéro de Passeport technique
* Type of entry : Trade, Legal, etc.
* Answer YES or NO
* Type d'engagement : Commercial, Légal, etc…
* Répondez par OUI ou par NON
* Type of entry : Private - Amateur
* Type d'engagement : Privé - Amateur
* Organisers' proposed advertising accepted
* Publicité proposée par les organisateurs acceptée
By my signature, I declare that all the information contained on this bulletin of engagement is correct. Moreover, I recognize and approve completely the
terms and conditions of the discharge above and I accept all the terms and conditions related to my participation in this test.
Par ma signature, je déclare que toutes les informations contenues sur ce bulletin d’engagement sont correctes. En outre, je reconnais et approuve
intégralement les termes et conditions de la décharge ci-dessus et j’accepte tous les termes et conditions liés à ma participation à cette épreuve.
Date :
ASN Stamp *
Signature of Entrant
Signature of Driver
Signature of Co-Driver
Timbre de l'ASN *
Signature du Concurrent
Signature du Pilote
Signature du Co-Pilote
Date :
Date :
Date :
* Or letter from entrant's ASN authorising and approving entry
* Ou une lettre de l'ASN des engagés autorisant et approuvant l'engagement
Please forward completed entry form to - Merci d'envoyer ce formulaire à l'adresse ci-dessous
RALLYE DE NOUVELLE CALEDONIE
B.P. 12 945 - MAGENTA
Phone : +687 761 540
98 802 - NOUMEA CEDEX
Fax : +687 442 744
NEW CALEDONIA
Website : www.rallye-nc.net
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