Rali Bryniau Clwyd 2022 - 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

Event Finals and Results will be available to download and will also be emailed to the address provided. If you would like a paper set posted to yourself please let us know here

E-mail/Website

Posted Paper

Driver

Full Name This must be filled in to continue

Address

Post Code

Home Town

Telephone Number

Mobile Number

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

Competition Licence Issuer

E-Mail Address

Club You cannot sign on until this is filled in

Club Membership No 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

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

E-Mail Address

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

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

Class You cannot sign on until this is filled in

E - Expert

S - Semi Expert

N - Novice

Insurance - Please Complete in Full

Insurers Name & Your Policy Number
If you are using the Jelf On Event Insurance Scheme please state Jelf otherwise please complete in full

Insurance Company's Address

Championships

Association of North Western Car Clubs Road Rally Championship

Crew Members Registered

None

ANWCC

WBCC

Driver Championship Registration Number

Co-Driver Championship Registration Number

Welsh Border CC

Crew Members Registered

None

ANWCC

WBCC

Driver 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

Event Name and Club

Year

Type

Overall Position

No of Starters

Fees - see above for how to pay

£110 which includes 2 x breakfasts

£

Club Membership £10 PER PERSON to riun to end of 2022

£

If using Bluefin £25 before any loadings

£

Total Money to be sent

£

Payment Method and Details This must be filled in to continue

Cheque - Made Payable to Broughton & Bretton Motor Club Ltd

Bank Transfer - See top of Page for details

Marshal Details

Name

Address

Post Code

Telephone Number

Mobile Number

Email Address

Experience

Important Details - Please Read

Please tell us your marshals preferred control type ( Time or Passage Control) and when during the event ( Early, Middle, End) they would like to marshal. Also if your marshal is able to do two controls please let us know. We will do our best to match your requirements, but cannot guarentee your marshal will get what they asked for.
NB: You will not be allowed to start unless your marshal has signed on and no refund will be given

***********VERY IMPORTANT NOTICE***************
ANY ENTRY MADE BY A PERSONS UNDER THE AGE OF 18 YEARS, WHETHER AS A DRIVER OR NAVIGATOR MUST BE MADE WITH A COMPLETE MSA PARENTAL CONSENT AUTHORISATION FORM. THIS FORM MUST BE FILLED IN BY A PARENT OR GUARDIAN. THIS CAN BE OBTAINED VIA THIS LINK -----MSA PARENTAL CONSENT FORM----
THIS FORM MUST BE RETURN TO THE ENTRIES SECRETARY BEFORE THE START OF THE EVENT

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 photographers so they may offer 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	HSBC
Sort Code	40-17-14
Account No.	52036479
Account Name	Broughton - Bretton Motor Club
Reference	Driver's full name.

Rali Bryniau Clwyd 2022 - Internet Entry Form

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