Detroit SCCA: Road Rally Entry Form

Detroit Region SCCA Road Rally Entry Form

EVENT NAME DATE CAR #

DRIVER NAVIGATOR

ADDRESS ADDRESS

CITY, ST ZIP CITY, ST ZIP

PHONE ( ) PHONE ( )

Email Email

REGION/NUMBER REGION/NUMBER

MINOR? (please circle) Y N MINOR? (please circle) Y N

Drivers License #/State

EMERGENCY INFORMATION

Notify Phone Notify Phone

Address Address

VEHICLE YEAR, MAKE, MODEL

COLOR LICENSE STATE INSURANCE CO

CLASS ENTERED (please circle) EQUIPPED LIMITED STOCK NOVICE OTHER

I hereby warrant that the above entered vehicle is on the road legally, is being used by the entrant with the owner's permission, and is covered by liability insurance of not less than $20,000/40,000/10,000 or the minimum requirements in the state of registry, whichever is higher. I further warrant that the vehicle is in safe operating condition and that the safety items listed below have been checked and are in good working order.

Entrant/Owner's signature

The driver warrants that she/he is in possession of a valid operators license.

Driver's Navigator's Signature Signature

How did you learn about this event? Detroit Region Rally Page on Internet WWW

Entry Fee Paid Date Rec'd Generals Mailed

VEHICLE INSPECTION The following items must be in proper working order: Rear view mirrors Headlights (HI/LO beams) Foot Brake Parking, tail, directional and stop lamps Parking Brake Horn Tires (condition of sidewall and tread) Windshield wipers and washers Seat belts (securely installed for driver and all passengers)

Print this form, fill it out in ink, enclose check for entry fee, mail to registrar or organizer.
Make checks payable to Detroit Region SCCA

Return to
Detroit Region SCCA Rally HomePage

This URL: http://pages.prodigy.net/murphybr/detrally/ent_form.htm

Date Created: January 23, 1996
Last Modified: February 12, 2000

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