TROFEO LANCIA 2025 - MODULO DI RICHIESTA DI ISCRIZIONE PILOTA

NAME*

First name*

Nationality*

Date of birth*

Date

Age at the date of the registration*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Mobile*

Area CodePhone Number

Email*

example@example.com

License number*

Type*

Country code*

National sporting authority*

NAME

First name

Mobile

Area CodePhone Number

Email

example@example.com

NAME & First name of the person or NAME of the team who will receive the prize money*

NAME & First name of the person or NAME of the team who will receive the vouchers *

Please mention the bank details to which prize money must be paid (IBAN + BIC + NAME of the bank account)*

Please mention the email address to which vouchers must be sent*

example@example.com

NAME of the team*

NAME of the legal entity or person owning the car*

Mobile*

Area CodePhone Number

Email*

example@example.com

Size of the race suit*

	Driver's choice	Codriver's choice (optional)
46
48
50
52
54
56
58
60
62
64
66

Clothing*

	Driver's choice	Codriver's choice (optional)
S
M
L
XL
XXL

Please use the following bank details for your payment:

AUTOMOBILES PEUGEOT

2 BOULEVARD DE L’EUROPE

78092 YVELINES CEDEX 9

IBAN : FR76 3000 3042 5000 0201 5002 850

BIC : SOGEFRPP

A sales order will be edited once this form will have been received. Payment can only be made as soon as this order will have been sent to the driver. No payment will be accepted without the possibility to link it with an existing order.

Registration type (incl. VAT)*

	Full Season (2.500€)	Discovery (850€)	Evoluzione Discovery (1.750€)	Discovery Last Chance (500€)
Choice

It’s mandatory for the applicant to attach an ID picture to this form for it to be fully considered and approved.

I, the undersigned (NAME, First name)*

hereby commit, as part of my registration for the TROFEO LANCIA 2025, to comply with the sports and technical regulations that I have already had the opportunity to review, both in form and in spirit, as well as the specific regulations for each rally.

I declare that I have been fully informed of the risks inherent in the practice of motorsport and accept them. I declare that I have been encouraged to take out personal accident insurance, covering any damage I may suffer, complementing the insurance included in my sports license to which I have adhered through the relevant federation.

I declare that I am in a state of health compatible with the practice of motorsport. I declare that I am not under the influence of any medication or other substances that could impair or alter my physical and/or mental faculties during the TROFEO LANCIA 2025.

I waive all claims, as well as those of my heirs and legal representatives, against STELLANTIS AUTO SAS, its parent company STELLANTIS NV, including all its subsidiaries, partners, collaborators, and/or subcontractors, for any damages caused or suffered directly or indirectly as a result of my participation in the TROFEO LANCIA 2025.

I declare that all the information provided above is accurate, and I am aware that any false declaration in this document may lead to my immediate exclusion from the TROFEO LANCIA 2025, with all amounts paid being forfeited to STELLANTIS AUTO SAS.

I acknowledge that the data collected is necessary for my registration request, that it is intended for STELLANTIS AUTO SAS, its group, partners, and service providers, and that in accordance with the European Regulation known as "GDPR" No. 2016/679 dated April 27, 2016, I have the option to individually exercise my right of access, information, rectification, opposition to communication, and deletion by sending a registered letter to the attention of the Data Protection Officer - STELLANTIS AUTO SAS at the address provided below.

STELLANTIS MOTORSPORT
to the attention of the Data Protection Officer
19 allée des Marronniers - 78000 VERSAILLES

Date*

Date

READ & APPROVED

Signature of the driver*

By checking this box, I agree to sign this information disclaimer without any reservation.

TROFEO LANCIA 2025 - DRIVER’S REGISTRATION FORM

REGISTRATION

LICENSE

CODRIVER

PRIZE MONEY

RALLY TEAM

RACEWEAR AND CLOTHING

REGISTRATION FEES

DISCLAIMER