Name: Email: Phone nr.: Company:
Name of the rally: Adress of the rally: Date of the rally:
Name of the driver: Type of car: Chassiss number: Production year: Value of the car (€):
-+
Surface: Gravel, tarmac or mixed: Number of stages: Total stage mileage:
Insurance requested crash damage: Insurance requested fire:
Visiting address: Varnaveien 34, 1523 Moss Mailing address: Pb 2171, 1521 Moss Organisation number: 920 890768