2012 RMVR PPIHC FORM

REGISTRATION IS NOW CLOSED



SECTION_1
Driver/Owner

CAR
Division RMVR
Racer_First
Racer_Middle
Racer_Last
Racer_nick_Name
Racer_Address
Racer_City/Town
Racer_State
Racer_Zip
Racer_Country
Racer_phoneH
Racer_phoneC
Racer_phoneW
Racer_phoneF
Racer_email
Racer_WebSite
MEDICAL INSURANCE - All drivers/riders and co-driver/riders MUST have medical insurance at the time of any PPIHC sanctioned event to participate.
Copies of proof of insurance must be provided at registration.

NOTICE TO ALL INTERNATIONAL PARTICIPANTS: Please verify with your health insurance company that your coverage extends to injuries resulting from participation in a racing event overseas as many policies specifically exclude coverage from racing injuries and/or injuries occurring overseas (outside of the coverage territory).

Racer_Insurance_Carrier
Racer_Insurance_Policy
Racer_Date_of_Birth
Racer ROOKIE PPIHC
Race Owner Same
Racer_Owner_First
Racer_Owner_Middle
Racer_Owner_LAST name
Racer_Owner_Address
Racer_Owner_City/Town
Racer_Owner_State
Racer_Owner_Zip
Racer_Owner_Country
Racer_Owner_phoneH
Racer_Owner_phoneC
Racer_Owner_phoneW
Racer_Owner_phoneF
Racer_Owner_email
Racer_Owner_WebSite

SECTION_ 2

Co-Driver

Racer_CoDriver_First
Racer_CoDriver_Middle
Racer_CoDriver_LAST
Racer_CoDriver_nick_Name
Racer_CoDriver_Address
Racer_CoDriver_City/Town
Racer_CoDriver_State
Racer_CoDriver_Zip
Racer_CoDriver_Country
Racer_CoDriver_phoneH
Racer_CoDriver_phoneC
Racer_CoDriver_phoneW
Racer_CoDriver_phoneF
Racer_CoDriver_email
Racer_CoDriver_WebSite
MEDICAL INSURANCE - All drivers/riders and co-driver/riders MUST have medical insurance at the time of any PPIHC sanctioned event to participate.
Copies of proof of insurance must be provided at registration.

NOTICE TO ALL INTERNATIONAL PARTICIPANTS: Please verify with your health insurance company that your coverage extends to injuries resulting from participation in a racing event overseas as many policies specifically exclude coverage from racing injuries and/or injuries occurring overseas (outside of the coverage territory).

Racer_CoDriver_Insurance_Carrier
Racer_CoDriver_Insurance_Policy
Racer_CoDriver_Date_of_Birth

SECTION_4
RACE CAR INFORMATION

Drive Train
Fuel Type
Car Frame
Car Year
Car Make
Car Model
Car Wheel base (")
Engine Make
Engine CI displacement
Car Weight (WET LBS)
Turbo
Rotary
Over Head Cam
Two Cycle
Four Stroke
Single Cylinder
Twin Cylinder
Side Car
Car Number Choice_1
Car Number Choice_2
Car Number Choice_3

Differential Manufacture
Transmission Manufacture
Transmission # of forward gears

SECTION_5

RACER HISTORY

 

Racer_History_PikePeak:
   

 

Racer_History_Other:
   


SECTION_6

SPONSORS, MEDIA,
Additional Information

Sponsor 1
Sponsor 2
Sponsor 3
Sponsor 4
 

Racer_Media:
   

Racer Staying @
Racing Vehicle @
Package Price
Total Paid
Purse Paid to
Racer Shirt Size
CoDriver Shirt Size

SECTION_7

PAYMENT

Entrant must qualify with Vintage Automotives rules posted on the RMVR website (www.rmvr.com)
2012 Vintage Division Automobile Entry Fees:
Entry, prior to February 1, 2012 $900.00
Late PAYMENT, After January 31, 2012 $1,100.00


Incomplete entry forms lacking any SECTION 5 infromation will not be accepted until all infromation has
been received by RMVR. The Vintage Division rebate program applies. More entries means more money back.
For more infromation go to www.rmvr.com. The rebate will range from approximately $100 to $400,
depending on the number and timing of the entries received. Eleven entries starts the rebate
program. A maximum number of 25 Vintage Division entries will be accepted.


Rebate checks will be mailed out to each entry at the conclusion of the event. Be sure to include your
mailing address for your rebate check on the entry form. Entry Packet and Entry Fees (must be by check)
must be mailed at time of submission (make ckeck payable to RMVR)
MAIL TO:
RMVR-PPIHC Vintage Automoble Division
c/o Rob van Westenberg
8245 S Wagon Wheel Rd
Morrison, CO 80465

THE ABOVE IS YOUR REGISTRATION FORM
In SUBMITTING you agree to enter the above 2012 PPHIC
In considerations of the rights and privilages to enter and participate in this event and other conciderations and intending to be legally bound setforth by the rules and regulations of RMVR and PPIHC

Please SUBMIT Form
        

Entry Fee

RMVR-PPIHC Vintage Automoble Division
c/o Rob van Westenberg
8245 S Wagon Wheel Rd
Morrison, CO 80465
+1 303 697 5475
rvanwest@rvanwest.com


For more information, contact race chairman
Arthur Porter
+1 719 577 4447
awpesq@comcast.com

Copyright 2012 All rights reserved.