Comp. Number

WALLASEY MOTOR CLUB LIMITED

Accident Advice Solicitors Racing Promenade Stages Rally

4th & 5th September 2015

HELD UNDER THE GENERAL REGULATIONS OF THE MOTOR SPORTS ASSOCIATION LTD.,

(INCORPORATING THE PROVISIONS OF THE INTERNATIONAL SPORTING CODE OF THE FIA) AND THE SUPPLEMENTARY REGULATIONS

 

 

 

 

ENTRY FORM

 

 

 

 

PLEASE USE BLOCK CAPITALS THROUGHOUT

 

 

 

 

DRIVER:

 

 

 

 

CO-DRIVER:

 

 

 

 

Full Name:

 

 

 

 

Full Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Club:

 

 

 

 

Club:

 

 

 

 

Licence Number:

 

 

 

Licence Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

Licence Grade:

 

 

 

 

Licence Grade:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Post Code:

 

 

 

 

Post Code:

 

 

 

 

E mail:

 

 

 

 

E mail:

 

 

 

 

Telephone Numbers:

 

 

 

Telephone Numbers:

 

 

 

Signature:

 

 

 

 

Signature:

 

 

 

 

 

 

 

 

 

 

 

 

Are you under 18

 

 

YES / NO

Are you under 18

 

 

YES / NO

If YES - SIGNATURE OF PARENT/GUARDIAN:

If YES - SIGNATURE OF PARENT/GUARDIAN:

 

 

 

 

 

 

 

 

NEXT OF KIN:

 

 

 

NEXT OF KIN:

 

 

 

Name:

 

 

 

 

Name:

 

 

 

 

Address:

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Number on event:

 

 

 

Contact Number on event:

 

 

 

ENTRANT/SPONSORS:

 

 

 

 

 

 

Name:

 

 

 

 

Licence No:

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHAMPIONSHIP DETAILS:

 

 

 

 

 

 

ANWCC

Yes / No

Reg. Number

 

ANWCC

Yes / No

Reg. Number

 

SD34

Yes / No

Reg. Number

 

SD34

Yes / No

Reg. Number

 

COMPETITION VEHICLE DETAILS:

 

 

 

 

 

Make:

 

 

 

 

Model:

 

 

 

 

Registration No:

 

 

 

 

Colour:

 

 

 

 

Capacity:

 

 

 

 

Class:

 

 

 

 

AWARDS:

 

 

 

 

 

 

 

 

 

Two Wheel Drive:

 

 

Yes / No

Mixed Crew:

 

 

 

Yes / No

Novice: (To be eligible for the Novice

 

Yes / No

Best Wallasey: (To be eligible for the

 

Yes / No

award both crew members must qualify as a

 

Best Wallasey award both of the crew must

 

Novice as defined per Blue Book H35.1.4.

 

 

be members of three months standing)

 

 

FOR OFFICIAL USE ONLY

Date & Sequence Entry Received

Date of Reply

Date Finals Sent

Payment Details

 

 

Accepted/Rejected/Held

/

/ 2015

 

/

/ 2015

/

/ 2015

 

SEEDING INFORMATION: Driver’s most recent results:

(Please complete fully in order for results to be taken into account when the event is seeded)

YEAR

EVENT

STATUS

OVERALL

CLASS

POSITION

POSITION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROGRAMME / WEB SITE:

Please give information on you & your car for any pre-event publicity & programme.

PAYMENT:

Entry Fee

 

£250.00

 

 

Payment 1 (Upon entering the event)

 

 

£100.00

Balance

(To be paid by 21st August)

 

 

£150.00

Wallasey Motor Club Membership(s)

@ £7.50

 

£

Marshal’s Donation

 

 

£

 

 

 

 

 

 

 

TOTAL

 

£

 

 

 

 

 

 

 

 

Please make all cheques payable to Wallasey Motor Club Ltd.

 

 

and post to: Tony King 26 Cheddon Way, Pensby, Wirral, CH61 8TR