Entry Form - Rotax Max Challenge Namibia

ENTRY FORM
NATIONAL LEG 7

Held under the International Sporting Code of the Federation International de I'Automobile (FIA), the General Rules and Standing Supplementary Regulations of Namibian Motorsport Federation and these Supplementary Regulations. Permit No. NMSF-PERM00XXX

Driver

Full Name and Surname *

Age *

ID Number *

License Number (NMSF) *

Tel. Work *

Tel. Cell *

Street Address *

Email Address *

Nominated Club *

Kart Number *

Entrant

Full Name and Surname *

License Number (NMSF) *

Street Address *

Tel. Work *

Tel. Cell *

Email Address *

Description of Kart

Chassis Brand *

Class *

Main Sponsor *

Other Sponsors *

Transponder Needed *

Transponder Number *

Purchase MOJO C2 *

Purchase Mojo D5

ENTRY COST TOTAL

Pre-race Declaration

Medical Aid Scheme *

Medical Aid Number *

Conditions to declare

Medication to declare

Preferred Hospital in case of EmergencyNOTE: Please be informed if no medical aid details provided, you will be transported to the nearest State Hospital in times when an accident happened and you need to be Hospitalised!!

Drug testing in sport is always possible, especially in cases of accidents or accidental death of co-drivers and /or spectators. It is the responsibility of the competitors to ensure that any medication taken prior or during the races should be cleared by a doctor or qualified pharmacist. Any condition, which might adversely affect your driving skills, must be notified at least one (1) hour prior to the start of the event to the doctor or the organizers. Willfully withholding any information might have serious legal implications.

I declare that the information is correct and I declare that I am fit to take part in this event.

Terms and Conditions

I, the undersigned, hereby agrees to indemnity found HERE

We hereby certify that we have read and understand the General Competition Rules and Standing Supplementary Regulations applicable to the competition as per our current Motorsport Hand Book. We further certify that the particulars are true and correct and that the vehicle entered complies with the regulations and vehicle specifications for the particular class / category / formula. We are aware of the penalty for non-compliance as per GCR 93 to GCR 94.

I agree to the terms above.

Please do not fill in this field.