Document Addressing E-Mail address for communication Real Name of this person Whom should we e mail information to? Driver Co-DriverAre a printed set of results required?
E-mail/Website Posted PaperDriver Full Name Address Post Code Home Town Telephone Number Mobile Number Competition Licence Number Competition Licence Issuer E-Mail Address Club Date of Birth Nationality Driver Publicity How Long Rallying? Notable Results Any other information Driver's Parent or Guardian (under 18 only) Name Address (if different) Post Code Telephone Number Relationship Co-Driver Full Name Address Post Code Home Town Telephone Number Mobile Number Competition Licence Number Competition Licence Issuer E-Mail Address Club Date of Birth Nationality Co-Driver Publicity How Long Rallying? Notable Results Any other information Co-Driver's Parent or Guardian (under 18 only) Name Address (if different) Post Code Telephone Number Relationship Car Details Make Model Colour Registration Number Engine Capacity Year Class B2 - Cars up to 1000cc & 1001cc to 1300cc B3 - 1301cc to 1600cc (excluding twin cam engined cars) B4 - 1601cc to 2000cc (Including twin cam engined cars but excl Porsche 911's) B5 - Cars over 2000cc including all Porsche 911's C2 - Up to 1300cc & 1301cc to 1600cc (excluding twin cam engined cars) C3 - 1601cc to 2000cc C5 - Over 2000cc, all and multi valve Twin Cam engined cars D2 - Up to 1300cc & 1301cc to 1600cc including 2 valve twin cam engined cars) D3 - 1601cc to 2000cc D4 - over 2000cc including twin cam multi valve engined cars D5 - All other twin cam multi valve engined cars E1 - Cars up to 1600cc E2 - Cars over 1601cc F1 - Cars up to 1600cc F2 - Cars over 1601cc G1 - Cars up to 1600cc G2 - Cars over 1600cc M1 - Up to 1400cc complying with MSA Regulations & Tyro specification M2 - Up to 1600cc complying with MSA Regulations & Typo specification M3 - Up to 1400cc complying with MSA Regulations M4 - 1401cc up to 2000cc complying with MSA Regulations (including FIA RS/R2T) M5 - 2001cc and over complying with MSA Regulations (including FIA R3/R3T) LR1 - British Armed Forces Motoring Association LR2 - Invited Land Rovers of similar type to BAFMA specificationFIA Homologation Number Insurance
If you require cover under the REIS Road Traffic Act Insurance Scheme payment must be included with your entry.
If you are arranging your own Road Traffic cover, please provide details below.Name Address Service vehicle Make Model Colour Registration Number Sponsor Sponsor Name (Note: this sponsor does not need an entrant's licence. If you have an entrant with an entrant's licence, please give details later. Championships The Fuchs Lubricants MSA British Historic Rally Championship Crew Members Registered None Driver Co-Driver BothDriver Championship Registration Number Co-Driver Championship Registration Number The Rally 2WD Challenge Crew Members Registered None Driver Co-Driver BothDriver Championship Registration Number Co-Driver Championship Registration Number The 2018 HRCR Motoscope Northern Historic Gravel Rally Championship Crew Members Registered None Driver Co-Driver BothDriver Championship Registration Number Co-Driver Championship Registration Number Person to be contacted in case of serious accident to Driver Name Address Post Code Telephone Number Relationship Will this person be attending the event? Person to be contacted in case of serious accident to Co-Driver Name Address Post Code Telephone Number Relationship Will this person be attending the event? Seeding - Past Performance on Rallies Scrutineering What time would you prefer to scrutineer? (TICK ONE ONLY) If no time is marked, ANY free time slot will be allocated
13.01 - 14.00 14.01 - 15.00 15.01 - 16.00 16.01 - 17.00 17.01 - 17.30Fees - see above for how to pay Entry Fee £ Insurance £0.00 - Using Own Insurance Cover 20.00 - REIS Insurance Cover Rallitrak £ Support the marshals £7.50 - Support the marshals - 1 sticker 15.00 - Support the marshals - 2 stickers 22.50 - Support the marshals - 3 stickers 0.00 - Support the marshals - not required Larger service bay plate £0.00 - Larger service bay plate - Not required 50.00 - Larger service bay plate Car parking adjacent to service area £0.00 - Parking adjacent to service area - Not required 10.00 - Parking adjacent to service area Guest Pack £0.00 - Guest pack 50.00 - Guest pack Total Money to be sent £ Pleas state payment method 1. Stripe (for card payments). 2. Cheque. 3. Bank Transfer Entrant (if applicable and not driver) No entry will be credited to an Entrant unless the Licence Number is quoted here. This licence MUST be produced at signing on. Name Address Post Code Telephone Number Nationality Competition Licence Number Competition Licence Issuer Privacy and Permissions We take your privacy seriously and will only use your personal information to administer your entry, including providing a public Entry List and sending you emails in connection with your entry. Some of your information will be passed on to the organisation providing results for the event.
We would also like to be allowed to contact you in the future to tell you about other events which we are running, including this event in future years. If you are happy to allow us to do this, please say so here.
No YesWe would also like to be allowed to pass on your Name, Address, Post Code and email addresses to Tom Irvin Photography so that they can contact you with a view to offering you photographss of you on the event. If you are happy to allow us to do this, please say so here.
No Yes
I understand that motorsport can be dangerous and accidents causing death, injury, disability and property damage can and do happen. I understand that these risks may give rise to my suffering personal injury or other loss and I acknowledge and accept these risks. In consideration of the acceptance of this entry I agree that neither any one of or any combination of the MSA and its associated clubs, the organisers, the track owners or other occupiers, the promotors and their respective officers, servants, representatives and agents (the"Parties") shall have any liability for loss or damage which may be sustained or incurred by me as a result of participation in the Event including but not limited to damage to property, economic loss, consequential loss or financial loss howsoever caused. Nothing in this clause is intended to or shall be deemed to exclude or limit liability for death or personal injury. To the fullest extent permitted by law I agree to indemnify and hold harmless each of the Parties in respect of any loss or damage whatsoever and howsoever arising from my participation in the Event.
I declare that to the best of my belief the driver(s) possess(es) the standard of competence necessary for an event of the type to which this entry relates and that the vehicle entered is suitable and roadworthy for the event having regard to the course and the speeds which will be reached.
I hereby agree to abide by the MSA Safeguarding Policy and Guidelines and the National Sporting Code of Conduct.
I have read and fully understood the Procedure for Control of Drugs and Alcohol as contained in the Competitors' and Officials' Yearbook Regulations H39, D35.1, G15.1.4 and have also fully familiarised myself with the information on the web sites referred to (www.ukad-org.uk and www.wada-ama.org ) in particular the UK Anti-Doping Rules which have been adopted by the MSA. Further, if I am counter-signing as the Parent or Guardian of a minor then in addition to the deemed consent to the testing of that minor (UKAD code Art 5.6.2) I hereby confirm that I give such consent for the minor concerned to be so tested.