ENG: This form must be completed directly on your computer and sent by email. FRA: Prière de compléter ce formulaire directement sur ordinateur et de l’envoyer par email.

ITA: Si prega di compilare il modulo al computer ed inviarlo via email.

DEADLINE FOR ENTRIES: 21.09.2016 at 23.59 hours – email: masters@fia.com 1

DRIVER

FIRST NAME

NAME

NATIONALITY (COUNTRY) ASN

INTERNATIONAL LICENCE

GRADE: LICENCE N°:

DATE OF BIRTH [DD/MM/YYYY] / /

ADDRESS

MOBILE ++

PHONE ++

EMAIL

COMPETITOR - IF IDENTICAL TO THE DRIVER, TICK THE BOX

COMPETITOR - TO BE COMPLETED IF SOMEONE OTHER THAN THE DRIVER

NAME

ASN

INTERNATIONAL LICENCE N°

ADDRESS MOBILE ++

EMAIL

VEHICLE

MAKE MODEL (EXACT TYPE)

MAKE OF THE ENGINE

CYLINDER CAPACITY cm3 TURBO or SUPERCHARGER: YES NO TECHNICAL PASSPORT N°

HOMOLOGATION N° (if applicable)

FUEL PETROL DIESEL ALTERNATIVE ENERGY

Specify:

SAFETY EQUIPMENT - Specify the conformity of the Driver’s safety equipment

The Driver’s safety equipment (safety harness, helmet, head restraining device, overalls, cagoule, gloves, etc.) is:

in conformity with the standards approved by the FIA.

This provision is obligatory for every Driver in the FIA groups (Categories 1 & 2 + Cat. 3 “Group E1-FIA”). The FIA safety list can be consulted on the FIA website.

in conformity with the standards approved by his or her ASN.

An additional safety form may be sent to the Driver by the organisation.

ENG: This form must be completed directly on your computer and sent by email. FRA: Prière de compléter ce formulaire directement sur ordinateur et de l’envoyer par email.

ITA: Si prega di compilare il modulo al computer ed inviarlo via email.

DEADLINE FOR ENTRIES: 21.09.2016 at 23.59 hours – email: masters@fia.com 2

MASTERS COMPETITION

ELIGIBILITY “MASTERS” CATEGORISATION Specify your criterion (criteria) for admission Specify the category and the group:

Specify your ranking / group / category

RANKING GROUP CATEGORY (DIVISION)

Among the first 12 in the FIA European Hill Climb Championship

CATEGORY 1 “PRODUCTION” / FIA

Among the first 12 in the FIA International Hill Climb Cup

GROUP:

Among the first 3 in an FIA Zone Championship Among the first 5 in a category of the National championship

CATEGORY 2 “COMPETITION” / FIA

Among the first 3 in a group of the National championship

GROUP:

Driver aged less than 25 years (born after 9 october 1991) – appointed by the ASN

CATEGORY 3 “OPEN” Female Driver – appointed by the ASN Group NATIONAL (non-FIA) Wild Card (request to be submitted in advance to the FIA Hill Climb Commission)

Specify GROUP: Specify TYPE:

Group E1 (FIA)

“MEDIA” FORM / DRIVER INFORMATION FIRST NAME NAME AGE

COUNTRY BIRTH PLACE (& REGION) ( )

PROFESSION MARITAL STATUS

DETAILS OF 1ST MOTOR SPORT COMPETITION Year: Discipline: Race:

DETAILS OF 1ST HILL CLIMB Year: Race:

CARS DRIVEN DURING CAREER

BEST RESULT(S) IN 2016?

BEST RESULT (CAREER)?

RECORD(S)?

HOBBIES?

PROJECTS?

ENG: This form must be completed directly on your computer and sent by email. FRA: Prière de compléter ce formulaire directement sur ordinateur et de l’envoyer par email.

ITA: Si prega di compilare il modulo al computer ed inviarlo via email.

DEADLINE FOR ENTRIES: 21.09.2016 at 23.59 hours – email: masters@fia.com 3

ORGANISATION OF THE PADDOCK NAME OF THE COMPETITOR

NAME OF THE DRIVER

TEAM MEMBERS - NUMBER

IS ANOTHER “MASTERS” DRIVER/VEHICLE PART OF THIS SAME STRUCTURE?

IF YES, INDICATE THE NAME OF THE 2nd DRIVER

CAR - NUMBER Length: m Width: m

TRAILER - NUMBER Length: m Width: m Height: m

TRUCK - NUMBER Length: m Width: m Height: m

ARTICULATED LORRY - NUMBER

Length: m Width: m Height: m

COMMON DECLARATION WE ACCEPT THE COMMON DECLARATION I. We confirm that we have read and understood the provisions of the International

Sporting Code and the applicable Sporting and Technical Regulations, and weagree, on our own behalf and on behalf of everyone associated with ourparticipation in the 2016 FIA Hill Climb Masters, to observe and be bound bythem (as supplemented or amended). We declare that we have examined thisEntry Form and that the information given is true, correct and complete. Weunderstand that any change to the details given on this Entry Form must benotified to the organisers and to the FIA, at the latest on the official closing datefor entries, so that the organisers and the FIA may reappraise our entry.

II. We understand that failure to notify the FIA of any changes made to the detailssupplied on this form may result in our exclusion from the FIA Hill Climb Masters.

III. We understand that only entries made no later than the closing dates and timesset by the FIA may be studied and then taken into consideration for the selectionof the participants. We understand that, in order to be valid, the entry must becompleted by all the documents required.

IV. We understand that any documents (copy of the Competitor’s licence, etc.) whichare not appended to the entry must be sent to the organisers and to the FIA (by email) before the given date.

V. We understand that any entries sent after this date will be considered null andvoid. The time of sending shown on the electronic communication will be used as conclusive evidence. We understand that any entries sent by fax will be refused and considered null and void.

VI. We understand that it is up to each Competitor to ensure that the informationgiven on the entry form is correct. The FIA accepts no responsibility in the event of false or incorrect information.

VII. We understand that the Driver must attend, if requested and invited to by theFIA, autograph sessions and any press conference and/or media sessionsorganised during the Competition.

VIII. We understand that our entry cannot be considered as definitive until theorganisers or the FIA have informed us of its validation.

OBLIGATORY DOCUMENTS TO BE SENT TO THE ORGANISATION - BY EMAIL + 1 ENTRY FORM COMPLETED, DATED AND SIGNED. + 1 COPY OF THE INTERNATIONAL DRIVER’S LICENCE. + 1 COPY OF THE INTERNATIONAL COMPETITOR’S LICENCE. + 1 COPY OF THE DRIVER’S LICENCE.

+ 4 PHOTOS, AT LEAST – HIGH RESOLUTION AND FREE OF ANY USAGE FEES MIN. 1000 KO / FORMAT JPG. MIN. 2 PHOTOS - PORTRAIT (IDENTITY) OF THE DRIVER IN OVERALLS. MIN. 2 PHOTOS - VEHICLE IN ACTION.

NO ENTRY FEE – DROIT D’ENGAGEMENT GRATUIT – KEIN NENNGEBÜHR – ISCRIZIONE GRATUITA - ŽÁDNÝ VKLAD

SIGNATURE – COMPETITOR SIGNATURE – DRIVER

DATE : / / 2016 DATE : / / 2016

The signature can be electronic or handwritten. *If signature is electronic: please insert the image (scan) of your signature in the appropriate field(s).*If signature is handwritten: please print the last page of the form, sign it and send the scan of this last page by email.