Entry Form

23.08 - 26.08.2012

Entrant

Name

Address

City

ZIP Code

Entrant Type

Town

State

Nationality

Mobile Phone

Email

In case of an accident

Name

Telefon

1st Driver

Name

Surname

Address

Town

City

State

Mobile Phone

Email

Nationality

Place of Birth

Date of Birth

Blood Group

Licence Nr.

Driving Licence Nr.

Driving Licence Expire

Hotel

2st Driver

Name

Surname

Address

Town

City

State

Mobile Phone

Email

Nationality

Place of Birth

Date of Birth

Blood Group

Licence Nr.

Driving Licence Nr.

Driving Licence Expire

Hotel

3st Driver

Name

Surname

Address

Town

City

State

Mobile Phone

Email

Nationality

Place of Birth

Date of Birth

Blood Group

Licence Nr.

Driving Licence Nr.

Driving Licence Expire

Hotel

Team

Team

Licence Nr.

Vehicle

Manufacturer

Model

Group/Class

Drive

Capacity

Plate Nr.

Chassis Nr.

Fuel

Invoicing

Company Name

Address

City

ZIP Code

State

VAT Nr.

Privacy We declare to be acquainted with the race’s regulations and to fully accept its terms. We clear the organizers from all responsibility in case of accident.

Marian Chytka Foto 2011

Robb Pritchard Foto 2011

HunGarian Baja 2011

HunGarian Baja 2010