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Club organisateur : CMP CHINY
Epreuve : C.C. LA ROCHE EN ARDENNE
Date : 29 MAI 2016
Bulletin d’inscription à renvoyer pour le 26 Mai 2016 (VOIE POSTALE UNIQUEMENT)
à 27, rue de la gare 6810 Izel
* C A S E S
Engagement reçu *
Le
……/………/……
R E S E R V E E S
Paiement reçu*
Le
A
L ' O R G A N I S A T I O N
DIVISION * CLASSE*
NUMERO ATTRIBUE*
……/………/………
PILOTE
Je, soussigné,
Nom :
(remplir en caractères d’imprimerie, svp)
Prénom :
……………………
Si pseudonyme :
Homme / Femme
…
………………………………………………/ « …………………… »
Né(e) le : …………………… Adresse : ……………………………………………………………… N° : …
Code postal : ……………………
Localité :
……………………
…
Si nous devons vous contacter : N°Tél/ GSM : ………………………E-mail : ………………………………………
Après avoir pris connaissance du règlement particulier de l’épreuve susnommée, m’engage à en observer toutes les prescriptions et certifie que les
présentes données sont exactes.
M’engage, en outre, à me soumettre à toute mesure du taux d’alcoolémie et contrôle de dopage qui me seraient imposés par l’Organisateur, par un
Officiel ou par les autorités compétentes.
Certifie, sur l’honneur, que le véhicule est conforme à la dernière réglementation de l’ASA et qu’aucune modification non autorisée n’y a été apportée.
LICENCE
ASAF
Province
;
Division 1
Division 2
Division 3
Division 4
Division
Histo Démo
Division
Access
VAS
N° Licence
BT
HT
LG
LX
NA
AN
LI
OV
VB
WV
†
†
†
†
†
†
†
†
†
†
Classe 1
Min. B
Classe 2
Min. B
(0 à 1400 cc)
(+ de 1400 à 1600 cc)
Classe 5
Min. B
Classe 6
Min. A4
(0 à 1400 cc)
(+ de 1400 à 1600 cc)
Classe 9
Min. Classe 10
Min. A4 Classe 11
Min. A3
A4
(+ de 1150 à 1400 cc)
(+ de 1400 à 1600 cc)
(0 à 1150 cc)
Classe 14
Min. A3
Classe 15
Min. A3
Kart-cross (0 à 650 cc)
(0 à 1600 cc)
(Voir art. 4.6 du RP CC/Sprint)
Licence minimale : L ou 1L-L
Jusqu'au 31/12/90
(Voir art. 4.7 du RP CC/Sprint)
1600cc max. – 150cv max.
Licence minimale : L ou 1L-L
Type
……………… ………
Classe 3
Min. A4
(+ de 1600 à 2000 cc)
Classe 7
Min. A4
(+ de 1600 à 2000 cc)
Classe 12
Min. A3
(+ de 1600 à 2000 cc)
Classe 4
Min. A4
(+ de 2000 cc)
Classe 8
Min. A4
(+ de 2000 cc)
Classe 13
Min. A3
(+ de 2000 cc)
Classe 16
Min. A3
(+ de 1600 à 2000 cc)
Parcours
non chronométré
Classe 17
Min. A3
(+ de 2000 cc)
Parcours
non chronométré
Pas de doublons
Pas de doublons
V E H I C U L E (remplir en caractères d’imprimerie svp)
Marque
Type
…………………….………… …………………….
Cylindrée
Division
……...cc
………. ………
Classe
Année
de fabrication
…………
Passeport technique ASAF n°…………………. N° POLICE Assurance : …………………….
ECURIE :
………………………………………………………………………………
Si Pilote seul (2) .…
$FRPSOpWHUVLSOXVLHXUVSLORWHVVXUODPrPHYRLWXUH
1RPGXƒ3LORWH
………………………………………………
(2) Cocher dans la case. Merci.
1RPGXƒ3LORWH
………………………………………………………
Voir article 11.2 du présent règlement particulier.
Date : ………………………
Signature du pilote, précédée de la mention « Lu et approuvé » : ………………………………………………………………
Numéro attribué à la voiture : ………..……
•
JOINDRE LA FICHE DES VERIFICATIONS ADEQUATE, COMPLETEE, AVEC VOTRE INSCRIPTION
Course de Côte / Sprint de LA ROCHE EN
ARDENNE
Date :29 MAI 2016
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Auteur
Документ
Catégorie
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