2023 NW200 Entry Form

COLERAINE & DISTRICT MOTOR CLUB LTD
FEDERATION INTERNATIONAL MOTORYCYLISTE
NORTH WEST 200, MOTORCYCLE ROAD RACES
7th – 13th May 2023

BULLETIN D'ENGAGEMENT/ENTRY FORM

FMNR - M.C.U.I. (U.C.) LTD

MCUI Permit No: 001/23

Held under the International Sporting Code of the F.I.M and the General Competition Rules of the M.C.U.I and the Clubs Supplementary Regulations.
The particulars required on this form must be completed in detail. Any entrant making a false or incomplete declaration may be disqualified. He/she will also be liable to such penalty as the Ulster Centre of the Motor Cycle Union of Ireland may inflict, subject to the Rules governing the right to appeal of any person.

Compulsory fields * These details must be entered fully or your entry will not be accepted!
Competitor information
Name*

First NameLast Name
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityCounty / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

DayMonthYear
Date
Nationality*
Preferred Start / Race No: (if possible)*
Are you a newcomer to the NW200*

YesNo
Newcomers must detail their racing experience to date*
FMN Country *
Licence No:*
Emergency Contact details at NW200 Event
Emergency Contact Name *

First NameLast Name
Relationship to you *
Contact Mobile Number *
Will this contact be with you at the event?*

YESNO
Please detail contact information of the person who will be at the event with you:
Race Entries- Thursday 11th May 2023
Which races do you wish to enter on Thursday?*

SupersportSuperstockSupertwin

Please fill in the following table with the necessary details- NOTE Please fill in your Thursday Full Chassis Number (failure to provide will void entry).Chassis number/s are a requirement to prove that it is a production chassis and not a one off special. Factory teams that do not have full chassis numbers should input their team identification number/s. Any machine that has no chassis number should provide a copy of the bill from a dealer for verification*

	Supersport	Superstock	Supertwin
MAKE
MODEL
CUBIC CAPACITY
YEAR OF MANUFACTURE
TRANSPONDER NUMBER
CHASSIS NUMBER

Race Entries- Saturday 13th May 2023
Which races do you wish to enter on Saturday? (Newcomers may only enter a max of 3 races on the Saturday)*

Sat 1st SuperbikeSupersportSupertwinSuperstockSat 2nd Superbike

Please fill in the following table with the necessary details- NOTE Please fill in your Saturday Full Chassis Number (failure to provide will void entry).Chassis number/s are a requirement to prove that it is a production chassis and not a one off special. Factory teams that do not have full chassis numbers should input their team identification number/s. Any machine that has no chassis number should provide a copy of the bill from a dealer for verification*

	Sat 1st Superbike	Supersport	Supertwin	Superstock	Sat 2nd Superbike
MAKE
MODEL
CUBIC CAPACITY
YEAR OF MANUFACTURE
TRANSPONDER NUMBER
CHASSIS NUMBER

NB - Machine models must be where applicable either approved or on the FIM 2022 Homologation List.

Please ensure you read the Technical rules and organisational requirements which are available on www.northwest200.org
Team Name/ Entrant/s
MCUI – UC & SC must have an entrant’s licence number. The Official Race Programme will only display the Team name of those holding a valid and current MCUI Team licence. If this licence number is not displayed here the Team/Entrant name will not appear in the race entries.*

Team Details- Please ensure that the Team Name is detailed below for each class-Fields are case sensitive *

	Machine	Entrant/Team Name
SUPERSPORT
SUPERSTOCK
SUPERTWIN
SUPERBIKE

GRID/ PADDOCK TEAM PASSES
This year all passes will be posted by recorded delivery to the person/address which you have provided below.

It is your responsibility to ensure the passes are posted to the person responsible for bringing them to the circuit and issuing them to the relevant personnel.

A total of eight passes will be provided which will allow access to the Grid/Paddock. A vehicle pass will also be provided to allow access to the paddock

The Competitor will receive two passes at sign on .

No other passes will be issued during the event.

If you have a need for passes to allow sponsors or another to access the paddock these can be purchased at the Ticket Office , which is situated opposite the paddock on the Coast side.

NOTE- It is your responsilbility to arrive with your passes. Failure to do so will result in charges.
Name*

First NameLast Name
Please enter a valid address for your passes to posted too.*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Information supplied in this form will used in our promotional material, so it is important ALL details are correct

You must read and agree to the following declaration and paragraphs below which are designed to create a legally binding relationship in return for your being allowed to enter and compete.

I declare that the above particulars are true and complete to the best of my knowledge.

I declare further, that I have read the Rules and Regulations governing the Competition and agree to abide by them and any further issued hereafter.

In consideration of the acceptance of this, my entry, I agree to save harmless and keep indemnified to Motor Cycle Union of Ireland, the Motor Cycle Union of Ireland, (Ulster Centre) Ltd, and the Promoting Club(s) (including the Owners or Lessees of land used for the event) and their respective Officials, Servants, Representatives or agents, from and against all actions, claims, costs, expenses and demands in respect of death of or injury to or loss of or damage to the person or property of myself or passengers or mechanic (as the case may be) how so ever caused arising out of or in connection with my taking part in this event, notwithstanding that the same may have been contributed to or occasioned by the said bodies, their Servants, Representatives or agents.   Furthermore, in respect of any parts of this event on ground where Third Party insurance is not required by law, this Agreement shall in addition to the Parties named above extend to all and any other Competitor(s) and their Servants and Agents and to all actions, claims, cost, expenses and demands in respect of loss or damage to the person or property of myself, my driver(s), passenger(s) or mechanic(s).

1.     I confirm that the information in this entry form my acceptance of the terms of my competition licence are correct.

2.     I confirm that I understand the nature of the competition I am entering and I am competent to take part

3.     I confirm that any machine that I use will comply with the regulations and will be safe and fit for use in the competition.

4.     I will satisfy myself (by sighting lap or otherwise) before taking part that the venue and track is acceptable to me with regards to its features and physical layout (unless prohibited to do so)

5.     I will not take part if I have any doubt about my ability or the safety of the venue.

6.     I accept that competition in motorsport may involve the risk of injury or death and I agree to take part at my own risk.

7.     Before taking part in the event I will read and be bound by and comply with any regulations and final instructions issued by the organisers, the circuit owners and the regulatory body

8.     I will not participate whilst under the influence of alcohol or intoxicating drugs and that if I am taking any prescribed medication I will inform the event organiser and seek approval to participate before taking part.

I agree to the above .....
Please select if you agree to all of the above rules and regulations*

Yes I agree to the above
Signature of competitor *

Clear
Signature of Entrant *

Clear
Date*

MonthDayYear
Date
Date*

MonthDayYear
Date
INSURANCE - Name and Address of the Company covering Personal Accident Insurance as required by F.I.M.

Please note: ACU, SACU and other competitors must have start permission that includes insurance and this must be obtained from FMN prior to arrival at this event. This must be emailed to Emir McLaughlin by Friday 28th April – emir@northwest200.org
Select one of the following employment categories which may apply to you in relation to your participation in this event. *

Employee – someone working under a contract of employment i.e. subject to the authority and instruction of the employerNon-employed – a person engaging in sport as a past-time/for pleasure rather than for financial benefit or professional reasons.Self-employed – person who works for gain or reward otherwise than under a contract of employment, whether or not he him-self employs other
COMPETITOR BANK DETAILS
ACCOUNT NAME *
ACCOUNT NUMBER*
SORT CODE *
IBAN
SWIFT CODE
Should be Empty:

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COLERAINE & DISTRICT MOTOR CLUB LTD

Competitor information

Emergency Contact details at NW200 Event

Race Entries- Thursday 11th May 2023

Race Entries- Saturday 13th May 2023

Team Name/ Entrant/s

GRID/ PADDOCK TEAM PASSES

COMPETITOR BANK DETAILS