Entry Form - Baja Portalegre 500

Nº
Provisório
Nº
Competição
↑ to be competed by the Organization↑
Entry Form
Licence nr.
* ENTRANT / COMPETITOR / CONCORRENTE
* Entrant / Competitor: Refer to articles 44, 45, 108, 109 and 110 of FIA Internat. Sporting Code
* Concorrente : conforme os Artº 44, 45, 108, 109 e 110 do Código Desportivo Internacional FIA
Name
Licença nº
Issuing ASN:
Nom / Nome
Emitida por:
Address
Town
Morada
Localidade
Postcode
País
Cod. Postal
Country
Mobile
Fax
Email
Licence nr.
DRIVER
Licença nº
Name
Surname
Nome
Apelido
Driving Licence
Nationality
ASN:
Carta Condução
Nacionalidade
Emitida por:
Address
Morada
Postcode
Town
Country
Cod. Postal
Localidade
País
Mobile
Phone
Fax
Telemóvel
Email
Birth Date
M
Data Nasc.
Licence nr.
CO-DRIVER
Name
F
Licença nº
Surname
Nome
Nome
Driving Licence
Nationality
ASN:
Carta Condução
Nacionalidade
Emitida por:
Address
Morada
Postcode
Town
Cod. Postal
Localidade
Telm.
Country
País
Phone
Email
Fax
Birth Date
Data Nasc.
M
Tech. Passaport
VEHICLE
P. Técnico nº
Make
Model
Plate nr.
Marca
Modelo
Matrícula
CC
Chassis Nr.
Homologation Nr.
Year
4 WD
Ano
FIA EVENT
2 WD
SOLO ( 1 driver only)
Classe
Group Grupo
T1
T2
F
Diesel
Petrol
Gasóleol
Gasolina
Advertising
Compulsory: BP ULTIMATE - CAMARA MUNICIPAL PORTALEGRE
Optional: VODAFONE – ACP
Entry Fee
T1 / T2
1.150 €
Safety Equipments *
SENTINEL
GPS-GSM
110 €
260 €
Total
1.520 €
* Competitors are required to purchase the fitting kit, bracket, power lead and antennae and pay a refundable deposit, that will be give
back after delivery of the systems in good condition.
IMPORTANT
This entry form will be valid if reaches the organization before 15/10/2010 with entry fees.
Entries received after 08/10 until 15/10/2010 will have an increase of 500 €.
Without the organiser's optional advertising: increase of 60%
Extra Service Plate
Van / Car
Auto/Furgão
Truck
250 €
500 €
Camião
Payment / Bank Transfer
Name:
Bank.
IBAN code:
Swift code:
Automóvel Club de Portugal
BPI
PT50001000002673878000172
BBPIPTPL
Please, send us the confirmation of the bank transfer
Fax nr +351 219 429 192
Notify in case of Emergency
Name: _____________________________________________ Mobile / Phone ___________________________
Service Crew mobile phone : _____________________________________________________________________
Palmares
Read and Approved
st
1 Driver
Data: ___/___/ 2010
2
nd
Driver
Data: ___/___/ 2010