Details of the Car

May 21 – 22, 2016

Competition Number :

ENTRY FORM

ENTRANT DRIVER CO-DRIVER Team Name First Name Last Name I/C @ Passport No. Nationality Date of Birth Blood Group Sex

Address

Contact No. Mobile Tel No Fax No Email Competition Licence No Issuing ASN Driving Licence No Country of Issue

DETAILS OF THE CAR Make Registration No. Model C.C. Group / Class Chassis No. Homologation No. Engine No. Country of Registration Predominant colour

FEES (Subject to 6% GST) ITEM AMOUNT CLOSING DATE TICK Entry - With organizers’ advertising (Private) RM500.00 Monday Entry - With organizers’ advertising (Team) RM1,100.00 16 May 2016 Entry - Without organizers’ advertising (All) RM2,200.00 1700hrs 3rd Party Insurance (Endorsement 24D) RM500.00

WHEEL SPORT MANAGEMENT SDN. BHD. Lot 2A, Jalan 13/2, Redberry City, 46200 Petaling Jaya, Selangor Darul Ehsan Tel : +60374951191 Fax : +60374951188 Email : [email protected] May 21 – 22, 2016

SEEDING INFORMATION (for Non-Malaysian first-timers only) Driver Name Car Group/Class Championship: Have you won a National Year: Championship?

1. Declaration of Indemnity In consideration of the acceptance of this entry and our being permitted to take part in the Meeting or Event detailed, I agree to save harmless and keep indemnified the FIA, AAM, Perlis state government, all government agencies and its staffs, Perlis Motorsports Club, Wheel Sport Management Sdn. Bhd., sponsors, all the owners and tenants of private property traversed, and the respective officials, fellow competitors, servants, representatives and agents from and against all losses, actions, claims, expenses and demands in respect of death, injury, loss or damage to persons or property of myself, my drivers, passengers or mechanics or any other persons whatsoever howsoever caused arising out of or in connection with this entry or taking part in the events this entry covers specified notwithstanding that such death, injury, loss or damage may have been contributed to or caused by the negligence of the Inviting Club or Automobile Association of Malaysia or the FIA or any of their respective officials, servants, representatives or agents or by any other person. 2. Ability to Control a Vehicle Declaration by Driver: I declare that should I at any time during this event suffering from any disability of any kind whether permanent or temporary which is likely to detrimentally affect my control of my automobile or my fitness to drive, I will not participate. 3. Consent: I consent to the details contained on this form being held by Perlis Motorsports Club and Wheel Sport Management Sdn. Bhd. for the purpose of the promotion and benefit of the Rally Event(s) concerned, and Motorsport in general. I acknowledge my right to access and correction of this information. 4. I also authorise the medical providers of the event to disclose medical information relevant to injury or illness sustained during the above mentioned event to Automobile Association of Malaysia and its officials. 5. Acknowledgement and Agreement By my signature I declare that all information contained on the Entry Form is correct and that I acknowledge and agree in full to the terms and conditions of the above indemnity and that I accept all the terms and conditions relating to my participation in this event.

ASN Stamp* Signature of Entrant Signature of Driver Signature of Co-Driver

* Or letter from the entrants’ ASN authorising and approving the entry

Date: _____ / ______/ ______

* Please email or send the complete entry form to the Rally Secretariat at the address below.

WHEEL SPORT MANAGEMENT SDN. BHD. Lot 2A, Jalan 13/2, Redberry City, 46200 Petaling Jaya, Selangor Darul Ehsan Tel : +60374951191 Fax : +60374951188 Email : [email protected]