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Maiden City Motor Club Ltd
Presents
Shackleton Charity Festival
Classic Rally
The competition will be held under the International Sporting Code of the FIA, the General Competition
Rules of Motorsport Association (the MSA) and the Regulations as published.
INDIVIDUAL ENTRY FORM
PLEASE CHECK THAT YOU HAVE DONE THE FOLLOWING
1. ENTERED ALL THE DETAILS OF FIRST DRIVER, SECOND DRIVER, AND ENTRANT.
2. ENTERED THE ADDRESS TO WHICH ALL CORRESPONDENCE SHOULD BE SENT.
3. ENTERED THE DETAILS OF THE CAR.
4. PLEASE INDICATE TO WHOM A REFUND SHOULD BE MADE.
5. ENTER SEEDING ORDER INFORMATION.
6. PLEASE GIVE NAME AND ADDRESS OF INSURERS.
7. SIGN THE ENTRY FORM UNDER THE DECLARATION OF INDEMNITY.
8. PLEASE ENSURE THAT YOU HAVE ENCLOSED THE CORRECT ENTRY FEE.
ENTRY FEE CLOSING DATE
Normal Rate £150 Friday 11th July 2008
Entry Fee in Sterling only please.
Please make cheques payable to: MAIDEN CITY MOTOR CLUB LTD.
Entries to be sent to: Donna Carlin
176 Highmoor Road
Eglinton
BT47 3HS
PRESS, RADIO, AND TV INFORMATION SHEET CAR No
PLEASE COMPLETE IN BLOCK CAPITALS
QUESTION FIRST DRIVER SECOND DRIVER
NAME
Date of Birth
Birthplace
Occupation
Address
Home Home
Telephone No’s
Business Business
Hobbies other than Rallying
How long competing in
Rallies?
Best 3 Rally results
Have you done the Dogleap Rally
before?
Your best results
Married?
Which regional TV company serves
your area
Which local radio stations serves
your area
Names of local newspapers
Make Capacity
Details of car
Group
Car History
(Details of special interest)
PLEASE COMPLETE THIS ENTRY FORM USING BLOCK CAPITALS.
PLEASE ENSURE THAT YOU HAVE COMPLETED ALL SECTIONS
CORRECTLY BY REFERING TO THE REGULATIONS WHERE APPLICABLE.
1.
DRIVER NAVIGATOR ENTRANT
SURNAME
FIRST NAME
ADDRESS
POSTCODE
DAYTIME/MOBILE
Please attach copy of
TEL No
Entrant’s Licence if an
NATIONALITY Entrant is specified.
COMP.LIC.No
ISSUED BY
DATE OF BIRTH
2. ADDRESS TO WHICH CORRESPONDENCE SHOULD BE SENT (DRIVER / NAVIGATOR)
3. DETAILS OF CAR
Make Model Year of Manuf Cubic Capacity Group Class F.I.A. No
4. IF A REFUND OF ENTRY FEE HAS TO BE PAID, INDICATE TO WHOM IT SHOULD BE PAID
DRIVER NAVIGATOR ENTRANT
5. SEEDING ORDER APPLICATION FORM
Please enter details of results achieved by the first driver only (as a first driver) during the past two years. This
information is for your benefit and if not received by the organisers, they will have no choice but to place you at the end
of the seeded entry list.
Overall Position
Event Year
Position in Class
INTERNATIONAL
EVENTS
NATIONAL EVENTS
OTHER EVENTS
PLACINGS IN
CHAMPIONSHIPS
OTHER EVENTS
6. Name and Address of Insurers
NEXT OF KIN DRIVER NAVIGATOR
NAME
Address
Telephone Number
7. Declaration of Indemnity
By the very fact of signing the entry form, the entrant, as well as the crew members submit themselves to the sporting jurisdictions
specified in the International Sporting Code of the FIA and accept unreservedly these regulations, the General Regulations of the Motor
Sports Association (MSA).
“I declare that I have been given the opportunity to read the General Regulations of the Motor Sports Association and if any the
Supplementary Regulations for this event and agree to be bound by them. I declare that I am physically and mentally fit to take part in
the event and I am competent to do so. I acknowledge that I understand the nature and type of the competition and potential risk
inherent with motor sport and agree to accept the risk. Further, I understand that all persons having any connection with the
promotion and/or organisation and/or conduct of the event are insured against loss or injury caused through their negligence.
I declare that the use of the vehicle hereby entered will be covered by insurance a required by law which is valid for such part of this
event as shall take place on roads as defined by the law.
If I an the Parent/Guardian/Guarantor of the driver “I understand that I shall have the right to be present during any procedure being
carried out under the Supplementary Regulations issued for the event and the General Regulations of the MSA.”
As the Parent/Guardian/Guarantor: “I confirm I have acquainted myself with the MSA General Regulations, and agree to pay and
appropriate charges and fees pursuant to those Regulations (to include any appendices thereto) and hereby agree to be bound by those
Regulations and submit myself without reserve to the consequences resulting from those Regulations (and any subsequent alteration
thereof). Further, I agree to pay as liquidated damages any fines imposed upon me up to the maxima set out in Section Z.
Note: Where Parent/Guardian/Guarantor is not present there must be a representative who must produce a written and signed
authorisation to so act from the Parent/Guardian/Guarantor as appropriate.
Signature of Driver Date
Signature of Navigator Date
Signature of Parent or Guardian Date
(If under 18 years of age)
Amount Enclosed Entry Fee at Standard Rate £150.00 __________
Entry Fee at Late Rate N/A __________
Club Membership ~ Driver £10.00 __________
Club Membership ~ Navigator £10.00 __________
Shakedown Fee N/A __________
Total Amount Enclosed £ __________
LATE OR TELEPHONE ENTRIES WILL NOT BE ENTERTAINED
For Official Use Only
Number
Received Acknowledged Amount in Sterling Class
