Entry Form

(*) required field

DRIVER

Name*
Surname
Address/N°
Zip code/Town
District
Country
Phone
Mobile
Email*
Date of Birth
Driving Licence N°
Expiring date
Ability level in regularity detection timing point
1 (<5 cent)2 (5-10 cent)3 (10-20 cent)4 (20-40 cent)5 (>40 cent)

VEHICLE

All car’s built before 31.12.1996 are admitted provided they are road registered with a regular licence plate, insurance and comply with the technical rules of the road; for cars built between 1996 and 1986, the organization reserves the right not to accept certain types of cars at its discretion.

Manufacture
Model
Year
Engine capacity
Plate
Insurance company
Number
Expiring date
Identity Card ASIFED
No
Number
Identity card FIVA
No
Number
Class seniority vehicle
A (<1904)B (<1918)C (<1930)D ('31-'45)E ('46-'60)F ('61-'70)G('71-'96)

CO-DRIVER

Name
Surname

CLUB-REGISTER

Name
Town

YOU ARE ASKING TO REGISTER TO:

Event name
Date
I choose to partecipate as member of the team:
GuelfiGhibellini

BOOKING CHECK-IN

The check-in on Saturday is reserved for people coming from the area out of Bologna
I book check-in Friday nightI book check-in Saturday morning

Note: (Please write any special request, like food allergies, or others and we will do our best to meet your needs)

ENTRY FEE

The entry form must be accompanied by the payment of the amount of Euro 340,00 to be received before March 6, 2016. From 7 to 25 March 2016 the amount is Euro 390,00. If the number of 100 entries is exceeded , we will open a waiting list in order to evaluate, from an organizational perspective, if it is possible to extend the entry to as many participants as practical. But in case it was not possible to accommodate all requests, entry fees will be refunded for those whose entry was received latest. The fee is for teams of two people and include lunch and dinner on Saturday 2 April , lunch of Sunday, April 3, 2016 and the free mechanical assistance along the entire route for both days, excluding any spare parts and consumables, provided by the garage Autoelite and Automaniabo, specialist in classic cars. Overnight accommodation is NOT included and is the responsibility of the entrant.
The payment must be made by bank transfer; on the account of Scuderia Automobilistica Modena Historica to the bank Banco Pop. Soc. Cooperativa - BSGSP (agency of Maranello - MO) - IBAN: IT 43 M 05034 66820 000000013284 - Swift code: BAPPIT21434

Send copy of the bank transfer of Euro
by email a segreteria@modenahistorica.it
or by Fax to +39 0536-920048

REGULATION AND RESPONSABILITY

Acceptance of Rules and Release of Liability

Entrant's declare for themselves and their co-driver to accept unreservedly the program and the rules of the event (available on request) recorded in calendar ASIFED-FIVA, to comply with all regulatory requirements and recognize the relevance of the Organizing Committee as a single judge who’s decision is final in all matters regarding the event. Further acknowledges and agrees that the application form will be subject to approval by the Organizing Committee in its sole discretion and is valid only after payment of the registration fee.
With the request for participation the entrant indemnifies the organizing committee from any liability for any theft, loss or partial damage suffered or caused to themselves or others, to property and persons.

*Yes, I agree to the regulation in its entirety, and to absolve the organization from any liability.

PRIVACY

Art. 23 D.lgs. n.196 of 30 June 2003

I have read the privacy policy and I agree with the treatment of my personal data, according to legislative decree Art.23 D.lgs. n.196 of 30 June 2003.

*Yes, I declare to understand the privacy policy and I agree to the processing of personal data.

A copy will be sent to you for your reference.