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FEDERATION INTERNATIONALE DE L'AUTOMOBILE

2012 FIA SUPER 2000 WORLD RALLY CHAMPIONSHIP

FOR DRIVERS

REGISTRATION FORM

THE APPLICANT (driver or team or ASN designated team)

Full name

Country and date of birth (If applicable)

Country of residence

Address

Tel

Mobile:

E-mail

Team name and address

(If different from the above)

Tel

E-mail

Team Manager (if applicable)

Tel

Mobile:

E-mail

Authorised representative(s) Title

with sole power to bind the entrant Title

Title

DETAILS OF REGISTRATION

Entrant national competition issued by

Licence number

Entrant name

(As mentioned on the licence)

Driver(s)*

Licence number(s)* issued by

I undertake to participate in each of the 7 Nominated Rallies. In accordance with Article 8.2.3 of the 2012 FIA World Rally Championship Sporting Regulations, my 7 Nominated Rallies are:

1. 17-22 January Rally Monte-Carlo (MCO) (

2. 09-12 February Rally Sweden (SWE) (

3. 29 March – 01 Apr. Rallye de Portugal (PRT) (

4. 22-24 June Rally of New Zealand (NZL) (

5. 02-08 August Rally Finland (FIN) (

6. 13-16 September Rally of Great Britain (GBR) (

7. 04-07 October Rallye de France - Alsace (FRA) (

8. 01-04 November RallyRACC Catalunya-Costa Daurada (ESP) (

(Please tick the 7 relevant boxes corresponding to your 7 Nominated Rallies)

I confirm that I have read and understood the provisions of the International Sporting Code, the Technical Regulations applicable to the group of cars participating in the 2012 FIA World Rally Championship Cup, the 2012 FIA World Rally Championship Sporting Regulations. I agree to be bound by them (as supplemented or amended) and furthermore I agree on my own behalf and on behalf of everyone associated with my participation in the 2012 FIA World Rally Championship Cup to observe them. I declare that I have examined this Registration Form and that the information given is true, correct and complete.

FOR THE APPLICANT:

SIGNED BY (SIGNATURE)

(PRINT NAME OF THE PERSON SIGNING)

Being a person duly authorised

to sign for and on behalf of

(PRINT FULL NAME OF APPLICANT)

Date

* optional

Thank you to return this form, duly completed and signed, no later than 12 December 2011 to the following e-mail address: acrepin@

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