The 2012 Challenge, Online registration

The 2012 Challenge, Online registration

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The 2012 Challenge

To join the event it is necessary to complete all parts of this form.
The Organising Committee will evaluate each request and will reply within 5 working days.
In case of acceptance, the registration must be confirmed with payment of the fee according to the instructions which will be forwarded.

Alternatively, you can download the application form, fill it, and send it back to us by fax (+39 0522 441633).

Fields marked with an asterisk * are mandatory.
** only one is mandatory.

DRIVER

Name*

Surname*

Date of birth*

Place of birth*

Address*

ZIP*

City*

Province*

Country*

email*

Phone*

Mobile phone*

Fax

Driving Lincence n.*

Expiry date*

CSAI Licence n. (not mandatory for foreign crews)

(*) for foreign crews a temporary sport license will be issued on arrival at the cost of 35 euro per person

Sex *		Size *

F	M	XS	S	M	L	XL	XXL

CODRIVER

Name

Surname

Date of birth

Place of birth

Address

ZIP

City

Province

Country

Phone

Mobile phone

Fax

Driving Lincence n.

Expiry date

CSAI Licence n. (not mandatory for foreign crews)

(*) for foreign crews a temporary sport license will be issued on arrival at the cost of 35 euro per person

Sex		Size

F	M	XS	S	M	L	XL	XXL

COMPETITOR (only if different from Driver)

Name

Surname

Date of birth

Place of birth

Address

ZIP

City

Province

Country

Phone

Mobile phone

Fax

CSAI Licence n. (not mandatory for foreign crews)

(*) for foreign crews a temporary sport license will be issued on arrival at the cost of 35 euro per person

Sex

F M

CLUB

Name

Address

City

Province

Phone

CSAI Licence n. (not mandatory for foreign crews)

(*) for foreign crews a temporary sport license will be issued on arrival at the cost of 35 euro per person

CAR

Make*

Model*

Year*

Number-plate*

Fiche CSAI**

FIA Heritage Certificate**

FIVA Id Card**

ASI Approval**

AAVS Certify**

Policy insurance n.*

Expiry date*

Insurance company*

OTHER INFORMATION

Accompanying/Service car (a call from the Secretary’s Office will follow)

Accommodation in two double rooms for single occupancy

Accommodation in SUITE

Privacy
According to D. Lgs. 196/03, the data collected will be used only to inform about the activities and initiatives of GranPremioTerrediCanossa and will not be disclosed to third parties. The conferment of data is optional, but without personal information will not be possible to provide the services requested. The interested party may exercise its rights under Art. 7, D. Lgs. 196/03. The holder of the treatment is GranPremioTerrediCanossa - Reggio Emilia, Italy.
Agree*

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