REGISTRATION FORM V H R S

16th TOUR DE CORSE HISTORIQUE from 03rd to 08th october 2016
REGISTRATION FORM V H R S
What to do to send the registration form :
This registration form must be completed and return before
2016, September 1st to :
TOUR DE CORSE HISTORIQUE
BP 15
20538 Porto-Vecchio Cedex
Contacts for registration :
Marie France AGOSTINETTI +33 (0)6 08 67 35 77
Michelle ou Jean Pierre PIERI +33 (0)6 12 35 92 01
Email : [email protected]
Organisation : José ANDREANI +33 (0)6 09 97 07 83
The present document must be sent together with :
- the payment of the entry
- a copy of the technical passport
- a copy of the driving licence of each crew member
- a copy of the fédéral licence of each crew member
•
Method of payement:
Entry fee:
3 900 €
Bank wire : IBAN :FR76 1027 8090 6700 0200 6620 139 BIC/SWIFT : CMCIFR2A
Date d’Inscription et N° de dossier
N° de Course
VHRS
Average chosen :
High
Intermédiate
COMPETITOR
CREW
Low
PILOT
COPILOT
Name or Entity
First Name
Nationality
Sex
Date and Place of birth
Address
Zip Code
Town
Mobil phone
E-mail
Driving Licence #
Date and place of delivery
Federal Licence #
ASN code
Size Clothe (S ;M ;L…..) (not delivered if not indicated)
RESERVE A L’ORGANISATION
Permis
pilote
Licence
pilote
Permis
copilote
Licence
Copilote
Laisser
Passer
Paiement
RACE #
Reminder : CREW NAME
VOITURE
PERIOD
BRAND :
YEAR
GROUP
Type :
Homologation file #
Date :
Registration # :
Technical passport # :
Group of Origin :
Cubic capacity
Cm3 :
I, the undersigned, declare that to the best of my knowledge all information provided above is correct. Moreover, I understand that it is my unique responsablity to ensure
that all the documents are valid, especially the driving licence, the vehicule ownership documents.
I declare that I enter the TOUR DE CORSE HISTORIQUE 2016 in full knowledege of the risks such a race involves and renounce in advance all responsibility on the part of
the organisers civil or penal, in case of bodily or material accident during the event.
I declare that I have read and approved the registration conditions featuring on registration file.
I declare that I have read and approved the specific regulations of the event.
Signature preceded by the words "read and approved"
PILOT
COPILOT
Observations administrative checks :
Opinion of Scrutineer :
CAR LOAN AUTHORISATION
I, the undersigned:
authorise
Mr.
To pilot my car, which registration number is :
Done in :
On :
Signature