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6-7 SEPTEMBER 2019

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Logo Sport Vlaanderen - Omloop van Vlaanderen

ENTRY

To submit a valid entry, please fill in this form completely. The fields marked with (*) are mandatory, to register online, we require an email address on which we can contact you. Please sign (driver and co-driver) the received entry form and bring this to the administration control on Friday.

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

Co Driver

Name
First Name
Date of birth
Nationality
Street + housenumber
Zip Code
City
Email
Mobile phone number
Paspoort No
Drivers licence
Country of issue
Licence number
Sport National Authority
In accordance with articles 5.4, 22.1 and 45.3.4 of the BRC Sporting Regulations, I confirm that my participation in this competition will NOT TAKE IN THE POINT AWARDS for my ranking in the Belgian Rally Championship.
Junior BRC
BRC

Car

Registration No Real cylinder volume Body No Motor No Predominanr colour Technical passport No

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

before 15/08 after 15/08
BRC € 1000 € 1150
BRC Historic € 1000 € 1150
BRC Junior € 900 € 1050
TER € 1000 € 1150
TER Historic € 1000 € 1150
ONRK € 1000 € 1150
M CUP € 650 € 850
PORSCHE EVENT € 750 € 900
MINI SPORT CUP € 750 € 900
STAGE MASTERS € 750 € 900
CRITERIUM € 400 € 500
SHAKEDOWN + € 50
NO PUBLICITY
CRITERIUM NO PUBLICITY
+ € 500
+ € 400
+ € 500

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