PokerStars Rally 2021 - Internet Entry Form

Document Addressing

E-Mail address for communication This must be filled in to continue

Real Name of this person This must be filled in to continue

Whom should we send Finals and Results to?

Driver

Co-Driver

Driver

Full Name This must be filled in to continue

Address

Post Code

Home Town

Telephone Number

Mobile Number You cannot sign on until this is filled in

Competition Licence Number You cannot sign on until this is filled in

Competition Licence Issuer You cannot sign on until this is filled in

E-Mail Address You cannot sign on until this is filled in

Club You cannot sign on until this is filled in

Club Membership No You cannot sign on until this is filled in

Date of Birth You cannot sign on until this is filled in

Nationality

Helmet Make You cannot sign on until this is filled in

Helmet Model You cannot sign on until this is filled in

Helmet Approval Standard (per K10.3.1) You cannot sign on until this is filled in

FHR Make You cannot sign on until this is filled in

FHR Model You cannot sign on until this is filled in

FHR Approval Standard (per K10.3.1) You cannot sign on until this is filled in

Driver's Parent or Guardian (under 18 only)

Name

Address (if different)

Post Code

Telephone Number

Relationship

Competition Licence Number

Competition Licence Issuer

Co-Driver

Full Name This must be filled in to continue

Address

Post Code

Home Town

Telephone Number

Mobile Number You cannot sign on until this is filled in

Competition Licence Number You cannot sign on until this is filled in

Competition Licence Issuer You cannot sign on until this is filled in

E-Mail Address You cannot sign on until this is filled in

Club You cannot sign on until this is filled in

Club Membership No You cannot sign on until this is filled in

Date of Birth You cannot sign on until this is filled in

Nationality

Helmet Make You cannot sign on until this is filled in

Helmet Model You cannot sign on until this is filled in

Helmet Approval Standard (per K10.3.1) You cannot sign on until this is filled in

FHR Make You cannot sign on until this is filled in

FHR Model You cannot sign on until this is filled in

FHR Approval Standard (per K10.3.1) You cannot sign on until this is filled in

Co-Driver's Parent or Guardian (under 18 only)

Name

Address (if different)

Post Code

Telephone Number

Relationship

Competition Licence Issuer

Car

Make You cannot sign on until this is filled in

Model You cannot sign on until this is filled in

Colour

Registration Number

Engine Capacity

Year

Forced Induction

No

Yes

Four Wheel Drive

No

Yes

In Car Camera Request

No

Yes

FIA Homologation Number

Competition Car Logbook Number You cannot sign on until this is filled in

Car Seats and Harnesses

Left Harness FIA Homologation Expiry Date You cannot sign on until this is filled in

Right Harness FIA Homologation Expiry Date You cannot sign on until this is filled in

Left Seat FIA Homologation Expiry Date You cannot sign on until this is filled in

Right Seat FIA Homologation Expiry Date You cannot sign on until this is filled in

Car Fire Extinguishers

Hand-held fire extinguisher make You cannot sign on until this is filled in

Hand-held fire extinguisher capacity You cannot sign on until this is filled in

Hand-held fire extinguisher last service date You cannot sign on until this is filled in

Plumbed-in fire extinguisher make You cannot sign on until this is filled in

Plumbed-in fire extinguisher capacity You cannot sign on until this is filled in

Plumbed-in fire extinguisher last service date You cannot sign on until this is filled in

Insurers

if you cannot comply with the criteria to use the events 3P insurance then please provide the following information to Ben.Willoughby@shepherdcompello.com:

Proof of insurance on your daily car
Claim and conviction history

Name You cannot sign on until this is filled in

Shepherd Compello

Own Insurance

Address

Service Crew 1

Contact Name

Contact Number

Service Crew 2

Contact Name

Contact Number

Service Crew 3

Contact Name

Contact Number

Service Crew 4

Contact Name

Contact Number

Service Crew 5

Contact Name

Contact Number

Recce vehicle

Make You cannot sign on until this is filled in

Model You cannot sign on until this is filled in

Colour You cannot sign on until this is filled in

Registration Number You cannot sign on until this is filled in

Contact Name

Contact Number

Service vehicle

Make You cannot sign on until this is filled in

Model You cannot sign on until this is filled in

Colour You cannot sign on until this is filled in

Registration Number You cannot sign on until this is filled in

Service vehicle length

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

ANWCC Stage Rally Championship

Crew Members Registered

None

Driver

Co-Driver

Both

Driver Championship Registration Number

Co-Driver Championship Registration Number

HRCR Stage Masters Historic Stage Rally Challenge

Crew Members Registered

None

Driver

Co-Driver

Both

Driver Championship Registration Number

Co-Driver Championship Registration Number

Motor-Mall (IOM) Manx Rally Championship

Crew Members Registered

None

Driver

Co-Driver

Both

Driver Championship Registration Number

Co-Driver Championship Registration Number

MRF Tyres Mixed Surface Rally Challenge inc ST Trophy

Crew Members Registered

None

Driver

Co-Driver

Both

Driver Championship Registration Number

Co-Driver Championship Registration Number

Protyre Motorsport UK Asphalt Rally Championship

Crew Members Registered

None

Driver

Co-Driver

Both

Driver Championship Registration Number

Co-Driver Championship Registration Number

SD34 MSG Stage Rally Championship

Crew Members Registered

None

Driver

Co-Driver

Both

Driver Championship Registration Number

Co-Driver Championship Registration Number

JD Tyres Welsh Tarmacadam Rally Championship

Crew Members Registered

None

Driver

Co-Driver

Both

Driver Championship Registration Number

Co-Driver Championship Registration Number

Person to be contacted in case of serious accident to Driver

Name You cannot sign on until this is filled in

Telephone Number You cannot sign on until this is filled in

Relationship

Will this person be attending the event?

Person to be contacted in case of serious accident to Co-Driver

Name You cannot sign on until this is filled in

Telephone Number You cannot sign on until this is filled in

Relationship

Will this person be attending the event?

Seeding - Past Performance on Rallies

Event Name and Club

Year

Type

Surface

Overall Position

No of Starters

Seeding - Competitor Opinion

Out of 130 entries, where do you think you should be seeded? This must be filled in to continue

Fees - see above for how to pay

Entry Fee

£

Driver Membership

£

Insurance

£

Co-Driver Membership

£

Shakedown Stage

£

Donation to Marshals Fund

£

Total Money to be sent

£

Payment Method and Details This must be filled in to continue

Telephone/Online transfer with drivers name as reference

Entrant (if applicable and not driver)

Name

Address

Post Code

Telephone Number

Nationality

Competition Licence Number

Competition Licence Issuer

Club Membership No

Marshal Details (please see article 19 in regulations)

Name

Telephone Number

Mobile Number

Experience

Comments

Anything else you'd like to tell us

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

Yes

We would also like to be allowed to pass on your Name, Address, Post Code and email addresses to Special Stage so that they can contact you with a view to offering you videos and photos of you on the event. If you are happy to allow us to do this, please say so here.

No

Yes

The event is not currently open for entries

Bank	Barclays
Sort Code	20-26-74
Account No.	00198587
Account Name	Manx Auto Sport Limited
Reference	Driver's full name.

PokerStars Rally 2021 - Internet Entry Form

Entries to this event are now closed and this page is for record only