PRIJAVNI LIST

PRIJAVNI LIST
BULLETIN D'INSCRIPTION DE REMPLACEMENT
MODULO D'ISCRIZIONE DI SOSTITUZIONE
REPLACEMENT ENTRY FORM
ERSATZ - ANMELDEFORMULAR
BOLETIN TIPO DE INSCRIPCIÓN
UTRKA - EPREUVE - EVENT - GARA - LAUF PRUEBA
FIA European Hill-Climb
Championship
"BUZETSKI DANI 2015"
Date: 19h.- 20th. September 2015.
NATJECATELJ - CONCURRENT - COMPETITOR - CONCORRENTE - BEWERBER - CONCURSANTE
Ime
Nom / Name
Nome
Name
Apellido
Prezime
Prénom / First name
Cognome
Vorname
Nombre
Nacionalnost
Nationalité / Nationality
Nazionalita
Nationalität
Nacionalidad
TEL.
Br. licence
Licence No.
N. Licenza
Lizenz Nr.
N. Licencia
Adresa
Adresse / Address
Indirizzo
Adresse
Dirección
Pseudonim
Pseudonyme / Pseudonym
Pseudonimo
Pseudonym
Seudonimo
FAX.
E-MAIL:
VOZAČ - CONDUCTER - DRIVER - CONDUTTORE - FAHRER - CONDUCTOR
Ime
Nom / Name
Nome
Name
Apellido:
Prezime
Prénom / First name
Cognome
Vorname
Nombre
Nacionalnost
Nationalité / Nationality
Nazionalita
Nationalität
Nacionalidad
TEL.
Br. licence
Licence No.
N. Licenza
Lizenz Nr.
N. Licencia
Adresa
Adresse / Address
Indirizzo
Adresse
Dirección
Pseudonim
Pseudonyme / Pseudonym
Pseudonimo
Pseudonym
Seudonimo
FAX.
E-MAIL
Palmares:
Molimo da zaokružite prvenstvo na kojem nastupate, Please circle the championship, Bitte kreisen Sie die
Meisterschaft, Si prega di cerchiare il campionato
FIA European
Hill Climb
Championship
FIA Historic
Hill Climb
Championship
CEZ Historic
Climb
Championship
Croatian
Championship
Croatian
Historic Hill
Climb
Championship
Slovenian
Championship
KUP AŠ 2005
Historic
KUP AŠ 2005
Austrian
Championschip
Austrian Historic
Hill Climb
Championship
34th International Hill-Climb Race “BUZETSKI DANI 2015”
AUTOMOBIL - VEHICULE - VEHICLE - VETTURA - FAHRZEUG - VEHÍCULO
GRUPA
GROUPE /GROUP
GRUPPE
/GRUPO_______________
Klasa
Classe/Class
Klasse / Classe _______________
Marka
Marque/Make
Marca
Marke
Marca_________________________
Tip
Type
Tipo
Typ
Modelo_____________________________
Obujam cilindra
Cylindrée/Cylinder capacity
Cilindrata /Hubraum
Cilindrada _____________________
Godina proizvodnje
Année construction /Year of man.
Anno di construzione
Baujahr /Aňo de construcción __________
Broj homologacije
Homologation No.
N. Homologazione
Homologotaion Nr.
______________
Broj cilindara / Nbre cylindres
Number od cylinder / N. cilindrata
Anzahl Zylinder
N. cilindros ____________________
Alésage /Bore
Alesaggio
Bohrung
Diametro ___________________________
Course / Stroke
Corsa
Hub
Carrera ______________________
Br. Šasije
Châssis /Chassis No.
N. telaio
Fahrgestell Nr.
N. bastidor _______________________________________
Br. Motora
Moteur / Motor No.
N.Motore
Motor Nr.
N. Motor _______________________________________
Svojim potpisom, natjecatelj/vozač potvrđuje kako prihvaća da će se bez iznimaka pridržavati svih propisa
objavljenih u posebnom pravilniku utrke.
Par sa signature, le concurrent/conducteur déclare accepter et respecter sans restriction toutes les
dispositions figurant au règlement particulier de l'épreuve.
With his signature, competitor/driver comfirms to accept and to keep without restriction all the provisions
published in the supplementary regulations of the event.
Com la sua firma, il concurrente/conduttore dichiara di accetare e di respettare senza restrizioni tutte le
disposizioni she figurano nel regolamento particolare della gara.
Durch sein Unterschrift bestätigt der Bewerber/Fahrer alle in der Veranstaltungsaussschreibung
veröffentlichten Bestimmungen zu akzeptieren und ausnahmslos einzuhalten.
Pore l moro hecho de firmar el boletin de inscripción, el concursante/conductor declara aceptar y someterse
sin ninguna restricción alguna, a todas las disposiciones esticular por el reglamento particular de la prueba.
TOUTE INSCRIPTION NON ACCOMPAGNEE DES DROITS SERA CONSIDEREE COMME NON VALABLE
EACH ENTRY NOT ACCOMPANIED BY FEES WILL BE CONSIDERED AS NOT VALID
L'ISCRIZIONE NON ACCOMPAGNATA DELLA RELATIVA TASSA SARA' CONSIDERATA NULLA
OHNE NENNGELD WIRD JEDE NENNUNG ALS UNGUELTIG BETRACTHTET
Mjesto i datum /lieu et date
Place and date / luogo e dana
Ort und Datum / Lugar y fecha ______________________
POTPIS – SIGNATURE – FIRMA – UNTERSCHRIFT FIRMA
natjecatelj - concurrent - competitor - concorrente - bewerber concursante
vozač - conducter - driver - conduttore - fahrer - conductor
The entry fee is made to the following account: HR71 2380 0061 1460 04610, IKB UMAG, SWIFT CODE
ISKBHR2X. CLOSING DATE FOR ENTRIES: Tuesday, 8th September, 2015 by midnight
AK „BUZET“, Korenika 27, 52420 Buzet, Croatia. Tel: 00385 99 662 1644; fax: ++385(0) 52 663 512
e-mail: [email protected] , http://www.buzetski-dani.com