ENTRY

Entrant

Team (*)
Name
Prénom
Nationality of the Licence
Address for correspondence (street/nr)
Zip Code
City
Email
Mobile phone number (*)
Licence number
Sport National Authority

Car

ENTRY FEES

For this entry form to be valid it must be accompanied by the appropriate entry fees, a receipt for the full amount paid to the entrants ASN, a bankers draft or details of a bank transfer, etc.

KBC / Code IBAN: BE43 4676 3593 3101 / Code Swift (BIC) KREDBEBB

Closing date 28/08/2019

SEEDING INFORMATION

FIA priority A driver
YES
NO

FIA priority B driver
YES
NO

Previous FIA seed
YES - Year NO

National seed
YES - Priority NO

National championship winner
YES - Year NO

FIRST DRIVER'S RESULTS

To be able to easily consult your results, we ask you to insert the link to your profile page on EWRC.

DECLARATION OF EXEMPTION OF RESPONSIBILITY

By the fact of its engagement, any competitor, driver or another licence holder exonerates the RACB, the RACB Sport, the organizers and their representatives, employees and each one of them in particular, from any responsibility in connection with the actions, expenses, fees, claims and complaints relating to the wounds (mortals or others), losses and damage caused with its person, with its goods, whatever the cause coming or resulting from its engagement or its participation in the « 60° ConXioN Omloop van Vlaanderen 2018 », that it is or not the direct or indirect consequence of a negligence or a fault of the aforesaid organizers, their representatives or their employees.

By ma signature I declare that all the information contained in the entry form is correct and that I acknowledge and agree in full to the terms and conditions of the above indemnity and that I accept all the terms and conditions relating to my participation in this event.

CONFIRM