DRIVER
First Name*
Surname*
Address:
House Name
House No and/or Road/Street
Village
Town*
County
Post Code*
Tel No. (Evening)*
Email
Motor Club (select only one)*
Age*
Licence Grade & Category*
Select
Rally International
Rally National A Stage
Rally National B Stage
Not Known
MSA Licence No
Championships:
MSA English*
Select
Yes
No
?
BTRDA Gold Star*
Select
Yes
No
?
BTRDA Silver Star*
Select
Yes
No
?
BTRDA 1400*
Select
Yes
No
?
BTRDA Rally 1st*
Select
Yes
No
?
MG ZR Challenge*
Select
Yes
No
?
Formula 1000*
Select
Yes
No
?
ASWMC*
Select
Yes
No
?
ACSMC*
Select
Yes
No
?
Mark Lovell*
Select
Yes
No
?
Name & Address of person to be contacted in case of an incident (do not state in Service Park or at Rally):
Name*
Tel No*
Address*
Will this contact be at the event*
Select
Yes
No
Co-Driver
First Name*
Surname*
Address:
House Name
House No and/or Road/Street
Village
Town*
County
Post Code*
Tel No. (Evening)*
Email
Motor Club (select only one)*
Age*
Licence Grade & Category*
Select
Kart International
Kart National A
Kart National B
Non-Race National B
Off-Road International
Off-Road National A
Off-Road National B
Race International
Race National A
Race National B
Rally International
Rally National A Stage
Rally National A Navigator
Rally National B Stage
Speed International
Speed National A
Not Known
MSA Licence No
Championships:
MSA English*
Select
Yes
No
BTRDA Gold Star*
Select
Yes
No
BTRDA Silver Star*
Select
Yes
No
BTRDA 1400*
Select
Yes
No
BTRDA Rally 1st*
Select
Yes
No
MG ZR Challenge*
Select
Yes
No
Formula 1000*
Select
Yes
No
ASWMC*
Select
Yes
No
ACSMC*
Select
Yes
No
Mark Lovell*
Select
Yes
No
Name & Address of person to be contacted in case of an incident (do not state in Service Park or at Rally):
Name*
Tel No*
Address*
Will this contact be at the event*
Select
Yes
No
CAR DETAILS:
Make*
Mobel*
Exact Engine CC*
Registration No*
Forced Induction*
Select
Yes
No
?
Four Wheel Drive*
Select
Yes
No
?
Class:
Class (SR7)*
Select
F1000/RF1.0
RF1.4
1.4L
1.4C
1.4S
B10
B11
B12
B13
N3
N4
WR1
H2
H3
SEEDING INFORMATION
Please detail the most recent relevant results (2010-2006) of the DRIVER ONLY. If you can not list all 9 previous events, please only fill in the ones you can and leave the remaining blank. This info will be checked
Event1 Date
Event1 Status
Event1 Event Name
Event1 Class Result
Event1 O/A Result
Event1 Start No
Event2 Date
Event2 Status
Event2 Event Name
Event2 Class Result
Event2 O/A Result
Event2 Start No
Event3 Date
Event3 Status
Event3 Event Name
Event3 Class Result
Event3 O/A Result
Event3 Start No
Event4 Date
Event4 Status
Event4 Event Name
Event4 Class Result
Event4 O/A Result
Event4 Start No
Event5 Date
Event5 Status
Event5 Event Name
Event5 Class Result
Event5 O/A Result
Event5 Start No
Event6 Date
Event6 Status
Event6 Event Name
Event6 Class Result
Event6 O/A Result
Event6 Start No
Event7 Date
Event7 Status
Event7 Event Name
Event7 Class Result
Event7 O/A Result
Event7 Start No
Event8 Date
Event8 Status
Event8 Event Name
Event8 Class Result
Event8 O/A Result
Event8 Start No
Event9 Date
Event9 Status
Event9 Event Name
Event9 Class Result
Event9 O/A Result
Event9 Start No
ENTRANT DETAILS:
Only complete this if you can show an MSA Entrant Licence
Full/Entrant Name
Licence No
Address
INSURANCE (see SR8)
Do you wish to use the Richard Egger (Road Traffic) scheme?*
Select
Yes
No
Can you sign the declaration as per SR8?*
Select
Yes
No
N/A
If using your own Insurance, please state the Name/Address of Company
Policy No
CORRESPONDENCE
Please send event information to*
Co-Driver
Driver
FEES
Please select either the fee or N/A (if you do not wish to purchase the service):
Entry Fee before Early Closing Date (14/04/09)*
Select
£400 - All Classes Not F1000/RF1.0/RF1.4
£350 - Class F1000/RF1.0/RF.14
Surcharge if entering from the 15/04/09 until 21/04/09 18:00
N/A
£40
Richard Egger Insurance (Road Traffic) Scheme*
Select
£20.00
N/A - Own Policy
Richard Egger Insurance (Road Traffic) Scheme - Insurance Excess?
Management Pack - SR13.5 (only 1 per entry allowed to be purchased)*
Select
£20.00
N/A
Marshals Rewqard Scheme - support our marshals by purchasing "We Supported a Marshal" sticker(s), one sticker per £5 donated, to esnure every Marshal receives a memento of the Rally
Marshals Reward Scheme*
Select
N/A
£5.00
£10.00
£15.00
£20.00
£25.00
£30.00
£35.00
I'm Paying via*
Select
Bank Transfer
PayPal
Cheque
Postal Order(s)
Payment Total
Cheque/Postal Order No(s)
If Paying by Cheque or Postal Orders, please make them Payable to "Somerset Stages Rally"
DETAILS OF PERSON MAKING THIS APPLICATION
First Name*
Surname*
Email Address of Person completing this Application*
IMPORTANT PLEASE READ BEFORE CLICKING SUBMIT
Your Entry will be marked as being received (on the date and time you submit this form on-line) if you are paying by PayPal or Bank Transfer we will email you with 24hrs with details on how to do this. If you are paying by cheque or postal orders you should send the correct payment asap. However you are paying for your entry you still need to send a printed version of this form (you can print this after clicking submit), then the Driver and/or Co-Driver (or at least one) needs to sign the entry form you print after clicking on submit and send it to us within 5 days of submitting this form online (you will be able to print your completed form after clicking on the submit button). If the printed copy of this form is received after 5 days (with the correct fee) it will be marked as being received on the date the printed version was received rather than the date of the on-line submitted copy.
Submitting this Entry Form, does not imply acceptance in to the event, acknowledgement of your entry will be sent to you in writing (or via email), upon receipt of your Entry Fee and Printed/Signed copy of the Entry Form.
The condition of this on-line entry is that you have read and agree to all the supplementary regulations.
If entry is withdrawn any refund, if paying by PayPal, will not include the 3.4% PayPal fee paid, the refund will be based on the actual total entry fee, before the PayPal fee is added.
This site is not secure, the data is sent via email in the same way as any other email you send, if you do not wish to send the data via email, please complete an Entry Form by hand form the regs (a printed version of this form is not acceptable).
Data Protection Act: The above information will be stored on computer for the distribution of competitor information, entry list's etc. We will only use the above information, for Somerset Stages Rally use only, your details will not be passed on to anyone else.
It is the responsibility of the person submitting this entry to check if no acknowledgement is received after the posted entry form is submitted. If your entry is not received, no back dated applications will be accepted under any circumstances.
Do you agree with the above conditions*
No
Yes
