Registration form

Event name: Rallye Défi 2017


Note : If your registration is not correctly filled, it will be refused, and will be effective only on entry fees reception.

 

Championship: National
National + RSQ
National + OPRC
RSQ
OPRC
Date: 
Seed:  
National class: Expert Novice
Regional class: Expert Novice/Clubman
Entrant:
Name: 
Phone:
E-mail:
Address:
City:   
Province/State: 
Postal Code: 
Driver:
Name: 
Phone:
E-mail:
Address:
City:   
Province/State: 
Postal Code: 
Driver's licence no.:
Province/State: 
Compet. licence no.:
CARS: National Regional
RA and NASA: National Division
Co-driver:
Name:
Phone: 
E-mail: 
Address: 
City:    
Province/State:
Postal Code:
Co-driver's licence no.:
Province/State:
Compet. licence no.:
CARS: National Regional
RA and NASA: National Division
Vehicle:
Class: Open 4WD Prod 4WD Open 2WD Prod 2WD
Make: 
Model: 
Year:  
Colour:
Engine displ.:
No. of cylinder: 
Licence plate no.:
Province/State: 
Insurance Co.:
Policy no.:
Sponsors:
Car name to be used in pub.:

REQUIRED:
Email adress for confirmation:

Click here to access a printable version of the waiver, it has to be signed and returned to the organizing committee to valid this present form.