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					                                                                             2012 FIA Super 2000 World Rally Championship - Registration Form




                            FEDERATION INTERNATIONALE DE L'AUTOMOBILE



                           2012 FIA SUPER 2000 WORLD RALLY CHAMPIONSHIP
                                             FOR DRIVERS
                                         REGISTRATION FORM




THE APPLICANT (driver or team or ASN designated team)

Full name                                               ..............................................................................................................

Country and date of birth (If applicable) ..............................................................................................................

Country of residence                                    ..............................................................................................................

Address                                                ..............................................................................................................
                                                       ..............................................................................................................
                                                       ..............................................................................................................
                                                       ..............................................................................................................
                                                       Tel .........................................................................................................
                                                       Mobile: ..................................................................................................
                                                       E-mail....................................................................................................

Team name and address
(If different from the above)                          ..............................................................................................................
                                                       ..............................................................................................................
                                                       ..............................................................................................................
                                                       ..............................................................................................................
                                                       Tel .........................................................................................................
                                                       E-mail....................................................................................................

Team Manager (if applicable)                           ..............................................................................................................
                                                       ..............................................................................................................
                                                       ..............................................................................................................
                                                       Tel .........................................................................................................
                                                       Mobile: ..................................................................................................
                                                       E-mail....................................................................................................



Authorised representative(s)                              ............................................. Title ......................................................
with sole power to bind the entrant                       ............................................. Title ......................................................
                                                          ............................................. Title ......................................................




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                                                                                    2012 FIA Super 2000 World Rally Championship - Registration Form
DETAILS OF REGISTRATION

Entrant national competition                                      ............................................. issued by ..............................................
Licence number

Entrant name                                                   ..............................................................................................................
(As mentioned on the licence)

     Driver(s)*                                         .....................................................................................................

     Licence number(s)*                                 .................................................. issued by ...................................


I undertake to participate in each of the 7 Nominated Rallies. In accordance with Article 8.2.3 of the 2012 FIA
World Rally Championship Sporting Regulations, my 7 Nominated Rallies are:


1.            17-22 January                        Rally Monte-Carlo (MCO)                                                                      

2.            09-12 February                       Rally Sweden (SWE)                                                                           

3.            29 March – 01 Apr.                   Rallye de Portugal (PRT)                                                                     

4.            22-24 June                           Rally of New Zealand (NZL)                                                                   

5.            02-08 August                         Rally Finland (FIN)                                                                          

6.            13-16 September                      Rally of Great Britain (GBR)                                                                 

7.            04-07 October                        Rallye de France - Alsace (FRA)                                                              

8.            01-04 November                       RallyRACC Catalunya-Costa Daurada (ESP)                                                      


(Please tick the 7 relevant boxes corresponding to your 7 Nominated Rallies)


I confirm that I have read and understood the provisions of the International Sporting Code, the Technical
Regulations applicable to the group of cars participating in the 2012 FIA World Rally Championship Cup, the
2012 FIA World Rally Championship Sporting Regulations. I agree to be bound by them (as supplemented or
amended) and furthermore I agree on my own behalf and on behalf of everyone associated with my
participation in the 2012 FIA World Rally Championship Cup to observe them. I declare that I have examined
this Registration Form and that the information given is true, correct and complete.


FOR THE APPLICANT:

SIGNED BY              ..............................................................................................................(SIGNATURE)

                      ..................................................... ............ .. (PRINT NAME OF THE PERSON SIGNING)
                      Being a person duly authorised
                      to sign for and on behalf of

                       ............................................................................... (PRINT FULL NAME OF APPLICANT)

Date ......................................................................................................................................................................


* optional


Thank you to return this form, duly completed and signed, no later than 12 December 2011 to the following
e-mail address: acrepin@fia.com
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posted:10/5/2012
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