subject_line
YPRES REVIVAL
ENTRY FORM
YPRES REVIVAL
INSCHRIJVINGSFORMULIER
YPRES REVIVAL
DEMANDE D'ENGAGEMENT
DRIVER
PILOOT
PILOTE
Last name
Familienaam
Nom de famille
*
First name
Voornaam
Prénom
*
Address
Adres
Adresse
*
Number
Nummer
Numéro
*
Box
Bus
Boîte
ZIP code
Postcode
Code postal
*
Town
Stad
Ville
*
Country
Land
Pays
*
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua & Deps
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Rep
Chad
Chile
China
Colombia
Comoros
Congo
Congo {Democratic Rep}
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland {Republic}
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar, {Burma}
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
St Kitts & Nevis
St Lucia
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Mobile number (used during event - incl country prefix)
Mobiel nummer (in gebruik tijdens evenement - incl land prefix)
Numéro de portable (utilisé pendant l'épreuve - prefix pays incl)
*
Email
E-mail
Email
*
CO-DRIVER
NAVIGATOR
CO-PILOTE
Last name
Familienaam
Nom de famille
*
First name
Voornaam
Prénom
*
Address
Adres
Adresse
*
Number
Nummer
Numéro
*
Box
Bus
Boîte
ZIP code
Postcode
Code postal
*
Town
Stad
Ville
*
Country
Land
Pays
*
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua & Deps
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Rep
Chad
Chile
China
Colombia
Comoros
Congo
Congo {Democratic Rep}
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland {Republic}
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar, {Burma}
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
St Kitts & Nevis
St Lucia
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Mobile number (used during event - incl country prefix)
Mobiel nummer (in gebruik tijdens evenement - incl land prefix)
Numéro de portable (utilisé pendant l'épreuve - prefix pays incl)
*
Email
E-mail
Email
*
CAR
WAGEN
VOITURE
Mark
Merk
Marque
*
Type
Model
Modèle
*
Building year
Bouwjaar
Année de construction
*
Cilinderinhoud (cc)
Engine capacity (cc)
Cylindrée (cc)
*
License plate
Nummerplaat
Plaque d'immatriculation
*
PALMARES - LANGUAGE
PALMARES - TAAL
PALMARÈS - LANGUE
History/palmares of the car and/or crew - previous Ypres Rally participations
(year, car, classification, anecdote)
Historie/palmares van de wagen en/of van het team - voorgaande Ypres Rally deelnames
(jaar, wagen, rangschikking, anekdote)
Historique/palmarès de la voiture et/ou de l'équipage - précédent participations Ypres Rally
(année, voiture, classification, anecdote)
*
ENTRY FEE
INSCHRIJVINGSTARIEF
PRIX D' ENGAGEMENT
Participation fee
Deelnamekost
Coûts de participation
*
car < 31.12.1986
car > 31.12.1986
INCLUDED
– set of road books (+/- 165 km) including Ypres Rally points of interest
– demo run on 2 closed road stages
– winter bar access
– Ypres Historic Regularity atmosphere
– car park Ypres
– lunch not included
Vegetarian food?
*
No
Yes (1 person)
Yes (2 persons)
Current Total:
0
€
Calculate
INVOICE INFORMATION
FACTURATIEGEGEVENS
DONNÉES DE FACTURATION
Invoice not required
Invoice required
An invoice will be sent after payment
Company name
Bedrijfsnaam
Entreprise
*
Last name
Familienaam
Nom de famille
*
First name
Voornaam
Prénom
*
Address
Adres
Adresse
*
Number
Nummer
Numéro
*
Box
Bus
Boîte
ZIP code
Postcode
Code postal
*
Town
Stad
Ville
*
Country
Land
Pays
*
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua & Deps
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Rep
Chad
Chile
China
Colombia
Comoros
Congo
Congo {Democratic Rep}
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland {Republic}
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar, {Burma}
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
St Kitts & Nevis
St Lucia
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
VAT number
BTW nummer
Numéro TVA
*
Email
E-mail
Email
*
DECLARATION OF LIABILITY
AFSTAND VAN VERHAAL
DECHARGE DE RESPONSABILITÉ
I accept without reservation the terms of the YPRES REVIVAL 2024 regulations and in particular its insurance provisions and scope of coverage. I understand that I should take out any additional insurance that I consider appropriate covering my own personal injuries, and, or, and property damage. I hereby agree to indemnity and hold harmless SuperStage vzw, its representatives and staff for any liability inrespect of personal injury, property and other damage suffered by me, arising from the competition and which would not be covered by the insurance taken out by SuperStage vzw for the YPRES REVIVAL 2024.
Ik aanvaard zonder voorbehoud de bepalingen van het reglement YPRES REVIVAL 2024 en in het bijzonder de reikwijdte van de dekking. Ik begrijp dat ik een aanvullende verzekering moet afsluiten die ik geschikt acht voor mijn eigen persoonsverwondingen en/of eigendomsschade. Ik ga hierbij akkoord met schadevergoeding tot SuperStage vzw, haar vertegenwoordigers en personeel voor enige aansprakelijkheid met betrekking tot persoonlijk letsel, eigendom en andere schade die ik heb geleden die voortkomen uit de wedstrijd en welke niet worden gedekt door de verzekering afgesloten door SuperStage vzw voor de YPRES REVIVAL 2024.
J’accepte sans réserve les termes du Règlement du YPRES REVIVAL 2024 et notamment les dispositions relatives aux assurances dont j’ai compris la description ainsi que la portée des garanties. J’ai bien noté qu’il m’appartient de souscrire toute assurance individuelle complémentaire que je jugerais utile concernant ma personne et, ou, mes biens et qui ne seraient pas indemnisés par les assurances souscrites par l’Organisateur à l’occasion du YPRES REVIVAL 2024.
*
I accept / Ik aanvaard / J'accepte