2022 Repco Rally New Zealand (National Event) Entry Form

Please note this Entry form is only for Competitors entering the National event of the 2022 Repco Rally New Zealand. All competitors in the International event must enter via https://registrations.fia.com/wrcnzl

Entries open 9 August.

Class entered *

NZRC1 (4WD or GROUP NZ 4WD)NZRC2 (NZRC 2WD) NZRC3 (OPEN CLASS 2WD)NZRC4 (HISTORIC CHALLENGE TROPHY)NZRC5 (NZ RALLY CHALLENGE TROPHY 4WD/2WD)

DRIVER DETAILS

Driver First Name *

Driver Last Name *

Driver Email Address *

Driver Mobile Number *

Driver Physical Address incl. City/Town and Postcode *

Postal Address (if different from physical)

Driver Date of Birth

Day

Month

Year

Driver Emergency Contact Name *

Driver Emergency Contact Mobile Number *Including country code e.g. +64

Contested less than 3 rallies? *

Driver Competition License Number *

Driver License Grade

Driver Expiry Date of Competition License *

Driver License Issuing ASN * *

Driver Financial Member of (Name of Club) *NZ Competitors only

Driver Expiry Date of Car Club Membership *NZ Competitors only

Driver Civil Drivers License Number *

Driver License Issuing Country * *

Driver Is your Civil Drivers License currently disqualified? *If YES, then you must sign a declaration at Documentation as per NSC 43(2)(b)

Co-Driver Details

Co-Driver First Name *

Co-Driver Last Name *

Co-Driver Email Address *

Co-Driver Mobile Number *

Co-Driver Physical Address incl. City/Town and Postcode *

Postal Address (if different from physical)

Co-Driver Date of Birth

Day

Month

Year

Co-Driver Emergency Contact Name *

Co-Driver Emergency Contact Mobile Number *

Contested less than 3 rallies? *

Co-Driver Competition License Number *

Co-Driver License GradeNZ Competitors only

Co-Driver Expiry Date of Competition License *

Co-Driver License Issuing ASN * *

Co-Driver Financial Member of (Name of Club)NZ Competitors only

Co-Driver Expiry Date of Car Club MembershipNZ Competitors only

Co-Driver Civil Drivers License Number *

Co-Driver License Issuing Country * *

Co-Driver Is your Civil Drivers License currently disqualified? *If YES, then you must sign a declaration at Documentation as per NSC 43(2)(b)

Entrant Details (if applicable)

Entrant Name (if applicable)

Entrant Email Address

Entrant Physical Address

Entrant Competition License Number and Grade

Entrant Expiry Date of Competition License

Vehicle Details

Vehicle Make *

Vehicle Model *

Registration Number *

Engine capacity (cc's) *

Year of Manufacture *

Log Book Number/ Technical Passport No *

Colour of Vehicle *

Other info

Name of Official representative authorised for the purpose of receiving any official notificationsEach competitor is required to nominate ONE official representative authorised for the purpose of receiving any official notifications, along with the respective contact (cellphone, Email).

Mobile Number of Official representative uthorised for the purpose of receiving any official notifications

Email Address of Official representative uthorised for the purpose of receiving any official notifications

Past experience to assist with seeding (Event, Seeded #, Finish Position)

Team Manager NameNOT Driver or Co-Driver (ie. team manager, spouse, crew that we can contact while rally is live)

Team Manager Mobile numberNOT Driver or Co-Driver (ie. team manager, spouse, crew)

Team accommodation name, address and phone number

Recce vehicle make (if known)

Recce vehicle registration (if known)

Recce vehicle colour (if known)

Will you be doing reconnaissance? *

YesNo

Will you be ordering notes (from www.allports.nz)? Must answer yes if doing recce or registering in NZRC *

YesNoAre available at a cost of NZ$280 per set. Competitors can order direct through Neil Allport Motorsport website www.allports.nz

Entry Fees *

NZRC Cat 1-4 National (2 Day) - $2,950Cat 5 (2 Day) - $2,490Please note $1,000 will be added to all entry fees if the competitor refuses organiser’s optional advertising.

Sustainability: How many riparian planting packages (bundle of plants) at $5 each would you like to donate via the Papakainga development in Raglan (Rākaunui 1B Ahuwhenua Trust) *Please add the donation price on to your entry fee when making payment. The Papakainga Development is run by a local Trust, they are replanting their 5.6 hectare block with natives, fruit trees and a community garden.

I will pay by: *

Bank depositCredit Card *please note a 3% transaction fee appliesPayment can be made to Rally New Zealand Club Inc bank account: ASB 12-3233-0608424-00 (Driver's last name as reference)

Credit Card Number

Expiry Date

Name of Card holder

I authorise the entry fees and other fees indicated on my entry to be charged to my credit card, as well as a 3% transaction fee.

Yes

Driver: I have read and acknowledge indemnity (see link below) *

YesPlease read the indemnity at https://www.rallynz.org.nz/2022-repco-rally-nz-driver-indemnity/

Co-Driver: I have read and acknowledge indemnity (see link below) *