GRUPPOPERONIRACE

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IMOLA 12 - 13 Ottobre 2019 Please send to/ Inviare a: GRUPPO PERONI RACE Srl Via Prati della Farnesina, 57 00135 - Roma – Italy a.casseri@gruppoperoni.it Fax: +39 06 45441336

ENTRANT DETAILS Entrant/Concorrente

Address/Indirizzo

Town/Città Postal Code/CAP

Phone number/Tel Fax

e-mail

Entrant Licence No./Licenza N.

VAT No/Partita IVA

Mail ing address if different/Indir izzo per la corrispondeza se diverso

Address/Indirizzo

Town/Città Postal Code/Cap

Phone number/Tel Fax

e-mail

Entry fee: CHAMPIONSHIP 500€ a vettura/car

GOLD 2.000,00 Euro plus VAT

BRONZE 2.000,00 Euro plus VAT

SILVER CUP 2.000,00 Euro plus VAT Banca Popolare Commercio e Industria IT 11 J 03111 03217 000000 096035

Deadline for inscriptions/Termine iscrizioni : 4 October 2019 – 4 Ottobre 2019

GRUPPOPERONIRACE

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1st Driver 2nd Driver

Surname/Cognome

Name/Nome

Address/Indirizzo

Town/Città

Postal Code/CAP

Date of birth/Data di nascita

Nationality/Nazionalità

Phone number/Tel

Fax

Mobile Phone/Cellulare

e-mail

Licence No./Licenza N.

3rd Driver Reserve Surname/Cognome

Name/Nome

Address/Indirizzo

Town/Città

Postal Code/CAP

Date of birth/Data di nascita

Nationality/Nazionalità

Phone number/Tel

Fax

Mobile Phone/Cellulare

e-mail

Licence No./Licenza N.

GRUPPOPERONIRACE

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CAR DETAILS/DETTAGLI VETTURA

Make/Costruttore Type/Modello Year of manufacture/ Anno di costruzione Cubic Capacity/

Cilindrata

No. of Electronic Passport / Numero passaporto elettronico

Weight/Peso

Fuel type/ Alimentazione

Benzina Diesel Turbocharged/Turbo

Yes No

Class/Classe

Car is equipped with FIA fast refuelling system/ La vettura è dotata si sistema di rifornimento FIA

Yes No

In signing the above entry form I, the Competitor, agree to the information and accept treatment of all communication including our Company details Please sign and stamp in the relevant space below

Entrant/Concorrente

1st Driver

2nd Driver

3rd Driver

Reserve

• To formally confirm that he/she has read and understood the ACI provisions governing the Italian Sportive activity and the International Sporting Code. He/she also declares to have read and understood the Sporting and Technical Regulations and expressly declares to accept them entirely. The Competitor agrees to be bound by them (as supplemented or amended) and furthermore agrees to observe on his/her own behalf and on behalf of everyone associated with his/her participation. • The Competitor hereby declares to indemnify and hold harmless the ACI, GRUPPO PERONI RACE, the Organizers, the Stewarts and all persons directly or indirectly involved in the organization and promotion of the races from any responsibility for damage or loss of whatever nature may arise out to the Competitor and to any other person connected in any way to the Competitor itself (Drivers, Employees, Consultants, Guests etc.) from the participation. • To unconditionally approve the Sporting and Technical Regulations of races in compliance to the articles1341 and 1342 of Italian Civic Code. • Furthermore he/she declares to commit himself/herself to have his/her Driver use the fireproof clothes and the helmet homologated according to the FIA regulation thus indemnifying the Organisers, the Stewarts and the ACI from any responsibility may arise in default of non-observance of the present commitment.

GRUPPOPERONIRACE

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SERVICE VEHICLES AND PIT ALLOCATION / MEZZI ASSISTENZA E SPAZIO PADDOCK

Entrant/Concorrente

Team Manager:

Phone / Mobile: A dedicated area with water and electricity connections will be allocated in the paddock to each entrant

Transport company/Compagnia Trasporto

Type of service vehicle/Tipo veicolo assistenza

Length/Lunghezza Width/Larghezza Box will be assigned to teams taking part to the event that have timingly applied. Garages will be assigned by the Organiser up to two different teams. Outside each it is forbidden to park any Camper or Caravan. If the box will be shared with another Team, only one truck each Team could be parked in front of the box. Box fares will be communicated by the Organiser or Circuit Management track bureau once its allocation has been confirmed. SERVICE VEHICLES/VEICOLI ASSISTENZA Please draw service vehicles layout.Disegnare l’ingombro del veicolo assistenza 0,5 mts (scale)