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1、 1 / 22017 中国新能源汽车拉力锦标赛中国新能源汽车拉力锦标赛 环洞庭湖站环洞庭湖站仅供赛事官员填写组别比赛号码ENTRY FORM 报名表 ENTRAN报报名名者者DRIVER车车手手CO-DRIVER领领航航员员 Team name 车队名称Surname 姓 First (given) name 名Photo 照片Date of birth 出生日期Nationality (as passport) 国籍 Passport/Re-Ent. Permit/ID No. 护照/ 回乡证/身份证 号码P/护照 R/回乡证 ID/身份证P/护照 R/回乡证 ID/身份证P/护照 R/回乡
2、证 ID/身份证Expiry Date 有效期Type of blood 血型 / Gender 性别Postal address 邮政地址Telephone No.固定电话Mobile phone No.移动电话Fax No.传真Email address 电子信箱地址Emergency contact person and telephone 紧急联系人及其电话 Driving licence NO.驾照号码Country of issue 发驾照国Competition licence NO. 比赛执照号码(如有请填) Issuing ASN 发赛照国家汽协(如有请填) Foreigne
3、rs Insurance policy NO. 外籍人员保险单号DETAILS OF CAR 参赛车辆描述（如自带车辆，请由报名人填写；如租用组织者提供的车辆，则由组织者填参赛车辆描述（如自带车辆，请由报名人填写；如租用组织者提供的车辆，则由组织者填 写）写） Bring your own car 是否自带车辆Yes 是 No 不 Plate No. 车牌号码Make 厂牌Registration No.行驶证号Model 车型Year of manufacture 出厂年份Theoretic mileage 理论里程Color 车身颜色Chassis No.底盘号码Charging Pile
4、 充电桩要求：国标（7 孔） 特殊标准（_孔）注：参赛车辆需配备一个灭火器、一套反光三脚架警示牌。如参赛车辆上牌，需提供车辆行驶证、车辆保险、合格证复印件。Group 组别组别2 / 2纯电动组纯电动组、 插电混合动力组插电混合动力组费用：免报名费，租车费：每辆费用：免报名费，租车费：每辆2000元元报名联系人：邓畅，电话：报名联系人：邓畅，电话：0731-88092968 联系人邮箱：联系人邮箱：DRIVER INFORMATION车手历史成绩信息车手历史成绩信息:Year 年份年份Event 赛事名称赛事名称Car 车辆车辆Group 组别组别Overall Position 全场排名全场
5、排名Group Position 组别排名组别排名No. of Finishers 完赛人数完赛人数DECLARATION OF INDEMNITY I have read the regulations issued for this event and agree to be bound by them and by the International Sporting code of the FIA.In consideration of the acceptance of this entry or of my being permitted to take part in this
6、event, I agree to save harmless and keep indemnified the Federation of Automobile and Motorcycle Sports of the Peoples Republic of China, the organizing committee, sponsor(s) and any other committee, commission, official, servant, representative and agent appointed by the organizing committee, inclu
7、ding any military or civil authority or personnel or any firm or individual connected with the organization or sponsorship of the rally, from and against all actions, claims, costs, expenses and demands in respect of death or injury to myself, my drivers, passengers or team members or the loss or da
8、mage to property of the aforesaid, howsoever caused, arising out of or in connection with this entry or my taking part in this event, and notwithstanding that the same may have been contributed to or occasioned by the negligence of the said bodies, their officials, servants, representatives or agent
9、s. Furthermore, in respect of any parts of this event where special stages take place, this agreement shall in addition to the parties name above extend to all and any other competitor(s) and their servants and agents.I declare that the drivers possess the standard of competence necessary for an eve
10、nt of the type to which this entry relates, also that the car entered is suitable and roadworthy for the event, and that the particulars given on the entry form are a true record.I declare that the use of the vehicle hereby entered below will be covered by insurance as required by the law which is v
11、alid for such part of the event that shall take place on the road defined by the law.I understand that should the driver(s) at the time of this event be suffering from any disability whether permanent, temporary or otherwise which is likely to affect prejudicially his normal control of the car, he m
12、ay not take part.I declare that the information given on this entry form is a correct statement of facts as verified by me免责声明免责声明 我已阅读过本赛事发布的规则，并同意接受此规则以及国际汽联运动法规的约束。 鉴于此报名被组织者接受并获准参加比赛，我同意在比赛过程中如发生我本人，我方赛手，乘客，车组人员的死亡、受伤或财产 的损失情况，将不向中汽摩联、组委会、赞助商、赛事委员会任命的官员、服务人员、代表、代理机构，以及参与组织、赞助拉 力赛有关的任何军队、地方机构、全体员
13、工、任何公司、个人提出追究及索赔的要求。而且，在进入赛段的比赛中，上述保证将 扩展到任何其他参赛者、服务人员及代理机构。 我声明赛员具备比赛要求的能力，赛车性能也符合赛事要求；此表所填写的各项内容属实。 我声明此处报名参赛的车辆会依照涉及赛事的有关法律的要求上有保险。 我同意如果赛员患有慢性、急性或其他影响其正常驾驶车辆的疾病或伤残，不能报名参加比赛。 我声明此报名表所填内容都经我核实，情况属实。ACKNOWLEDGEMENT AND AGREEMENT By my signature, I declare that all the information contained on the e
14、ntry 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. 承认和同意承认和同意 通过签字确认，我声明报名表上所有的信息都是准确的，我承认并完全同意上述免责声明中的条件和条款，并接受与本次赛事所 有相关的条件和条款。 Signature of Entrant 报名者签名Signature of Driver 车手签名Signature of Co-driver 领航员签名Date 日期
