ࡱ > 5 bjbj . пdпd 8 I = j* x A A A A A ) ) ) ) ) ) ) $ - 0 n ) u x ^ ) A A 7 $* 4% 4% 4% A A ) 4% ) 4% 4% ( ]( A 0;N " )( u) :* 0 j* 1( , 1 # 1 ]( 1 ]( 4% ) ) 4% j* 1 : Organising Club : Hainaut Motor Club RALLYE SALAMANDRE 2018 21 & 22 Avril 2018 NEntry form to send back (by normal post only) to Boiteux Monique, 6 place de la Filature 6500 Leval-Chaudeville, Belgium between 9 March 2018 and 18 April 2018. Email copy to info@salamandre-rally.be * reserved to organiser Engagement re u * P a i e m e n t r e u * O r d r e d i n s c r i p t i o n * D i v i s i o n * L e & . / & . . . . / & & . L e & . / & . . . / & & C l a s s e * D r i v e r ( i n c a p i t a l l e t t e r s p l e a s e ) I u n d e r s i g n , ( d r i v e r ) N a m e : & & & & & & & & & & & & & & & & & & / & & & & & & & & F i r s t n a m e : & & & & & & & & m a l e / F e m a l e B o r n o n : & & & & & & & & A d d r e s s : & & & & & & & & & & & & & & & & & & & & & & & & N : & P o s t c o d e : & & & & & & & & c i t y : & & & & & & & & A g r e e d o n t a g r e e b e i n g p u t o n a r e s e r v e l i s t s h o u l d t h e m a x i m u m n u m b e r o f e n t r i e s b e r e a c h e d . C o n t a c t d e t a i l s : M o b i l e n u m b e r : & & & & & & & & E - m a i l : & & & & & & & & & & & & & & & A S A F M S A C o m p e t i t i o n L i c e n c e # T y p e M o t o r c l u b B T H T L G L X N A o o o o o & & & & & & & & . . & & & & & & & & & & & & & C o d r i v e r ( i n c a p i t a l l e t t e r s ) N a m e : & & & & & & & & & & & & & & & & & & / & & & & & & & & F i r s t n a m e : & & & & & & & & M a l e / F e m a l e B i r t h d a t e : & & & & & & & & A d d r e s s : & & & & & & & N : Post Code : City : Contact details : Mobile number : E-mail: ASAF MSACompetition licence #TypeMotor clubBTHTLGLXNA o o o o o & & & & & & & & . . & & & & & & & & & & & & & V E H I C L E : M a n u f a c t u r e r : & & & & & & & . . . . . . . . . . . . T y p e : & & & & & & & & . . . . . . . R e g i s t r a t i o n p l a t e : . . . . . . . . . . . . . . . . & & & & Y e a r o f m a n u f a c t u r e : & & & . C h a s s i s n u m b e r : & & & & & & & & & & & & & . . . . . . . . . C y l i n d e r c a p a c i t y : & & & & & & c c Divisions 1,2,3 et 4 Division 1Classe 1 Min. A4 (0 1400 cc)Classe 2 Min. A4 (+ de 1400 1600 cc)Classe 3 Min. A3 (+ de 1600 cc)Division 2Classe 4 Min. A4 (0 1400 cc)Classe 5 Min. A4 (+ de 1400 1600 cc)Classe 6 Min. A3 (+ de 1600 2000 cc)Classe 7 Min. A3 (+ de 2000 cc)Division 3Classe 8 Min. A4 (0 1400 cc)Classe 9 Min. A3 (+ de 1400 1600 cc)Classe 10 Min. A3 (+ de 1600 2000 cc)Classe 11 Min. A3 (+ de 2000 cc)Division 4Classe 12 Min. A3 (0 1600 cc)Classe 13 Min. A3 (+ de 1600 2000 cc)Classe 14 Min. A3 (+ de 2000 cc) Classe 15 Min. A3 (=Div. 1 ou 2, + de 2500/3000cc) (pneus de tourisme) Divisions PH Classic et PH S/R Classe 16 Min. A4 (+ de 1300 1600 cc)Classe 17 Min. A4 (+ de 1600 2000 cc)Classe 18 Min. A4 (+ de 2000 cc)Division S/R Min. A3 (Toutes cylindres)Division Histo-DmoToutes cylindres - Licence minimale: R (VAS), L ou 1J-L If the co driver has no driving licence he should explicitly mention before signing below the following statement "Je m'engage sur l'honneur ne piloter en aucune circonstance". Having read the supplementary regulations of the event we commit to strictly follow all its prescriptions and certify that the data provided in the present form are correct. We also certify that the vehicle complies with the ASAF regulations and that no unauthorised modification has been brought to it. We do authorize ASAF to perform any check included in its Sporting regulations in order to verify this compliance. We also agree to submit ourselves to anti-doping and anti-alcohol tests which might be requested by the event organisers, by the officials or by competent authorities. Done in . on // [.] (Please write "Lu et approuv" /read and approved) Signature of driver Signature of co driver Please attach your palmars Rallye Salamandre 21 et 22 Avril 2018 N :VERIFICATIONSID information to be filled in by competitorDriver (capital letters)Name: Frist name: Signature: Province: ASAF MSACompetition Licence number % & I J ` a b ïÛvbN:- h ~ 5CJ OJ QJ ^J 'hK/ h&1 5CJ OJ QJ ^J mH sH 'hK/ hZ 5CJ OJ QJ ^J mH sH 'hK/ hZ 5CJ OJ QJ ^J mH sH !h ~ 5CJ OJ QJ ^J mH sH 'hK/ h&1 5CJ OJ QJ ^J mH sH 'hK/ hG 5CJ OJ QJ ^J mH sH 'hK/ hG 5CJ OJ QJ ^J mH sH 'hK/ hZ 5CJ OJ QJ ^J mH sH 'hK/ hZ 6CJ OJ QJ ^J mH sH 'hK/ hK/ 6CJ OJ QJ ^J mH sH & a M [ kd $$If 40 "|) *# ` 6PR ) 4 4 F a f4 $7$R&P#$/ G$ If ]7a$ 7$R&P#$/ If ]7gdK/ 7$R&P#$/ If ]7 7$R&P#$/ G$ If ]7 6 8 9 : b c ͿxbJb4 +h#x~ h#x~ 6CJ OJ QJ ^J aJ mH sH .h ~ h ~ 6CJ OJ QJ ^J aJ mH o(sH +h ~ h ~ 6CJ OJ QJ ^J aJ mH sH h ~ h ~ mH sH (h#x~ hZ CJ OJ QJ ^J aJ mH sH "h#x~ CJ OJ QJ ^J aJ mH sH (h#x~ h#x~ CJ OJ QJ ^J aJ mH sH hZ CJ OJ QJ ^J aJ hZ 5OJ QJ ^J hZ 5CJ OJ QJ ^J h&1 5CJ OJ QJ ^J h#y 5CJ OJ QJ ^J 쫕lWD3l h#x~ hZ OJ QJ ^J mH sH $h#x~ hZ CJ OJ QJ ^J mH sH (h#x~ hZ CJ OJ QJ ^J aJ mH sH $h#x~ hZ CJ OJ QJ ^J mH sH +h#x~ hZ 5CJ OJ QJ ^J aJ mH sH +h#x~ hZ 6CJ OJ QJ ^J aJ mH sH .h>H h#x~ 56CJ OJ QJ ^J aJ mH sH +h#x~ h#x~ 6CJ OJ QJ ^J aJ mH sH %h ~ 6CJ OJ QJ ^J aJ mH sH %h#x~ 6CJ OJ QJ ^J aJ mH sH t h X E $d $If ^a$gd#x~ $d $If ^a$ $d ^a$ Y kd $$If 40 "|) *# 6PR ) 4 4 F a f4 $7$R&P#$/ G$ If ]7a$ d m $R&P#$/ G$ If gd#x~ * R V X h j l n p v ȴȇnn]K@6@ h&1 OJ QJ ^J h&1 OJ QJ \^J #h#x~ h&1 OJ QJ \^J mH sH h#x~ h&1 OJ QJ ^J mH sH 1h#x~ h&1 5>*CJ OJ QJ \^J aJ mH sH &h#x~ h&1 5OJ QJ \^J mH sH 1h#x~ h&1 5>*CJ OJ QJ \^J aJ mH sH &h#x~ h&1 5>*OJ QJ ^J mH sH )h#x~ h&1 5>*OJ QJ \^J mH sH $h#x~ hZ CJ OJ QJ ^J mH sH h#x~ CJ OJ QJ ^J mH sH * 8 X l n y m m m _ $$G$ If a$gdG o# $G$ If $G$ If $$G$ If a$s kdF $$If F 0 ) 4 F a