Transcription
Application for a Motorsport UKCompetition LicenceGet to the heart of the action quickerby having the following to hand:999Read the ‘What you need to know about your motorsportlicence’ booklet (available in the Resource Centre ofwww.motorsportuk.org) before filling in this form.A ‘passport style’ imageYour medical/vision test (ifrequired - see section 4)Payment detailsNeed your licence in a hurry?3-hour processing, enclose an extra 115Any questions?3-day processing, enclose an extra 65We are happy to help - call us on 01753 765050Did you know you may be able to apply foryour licence online?SOME OF OUR LICENCE HOLDER BENEFITS (Login to your member benefits portal online for more details)Free fuel card with savingson petrol and diesel10% off in-storeUp to 120 cashback onroad tyre purchasesSECTION 1A YOUR DETAILS (Please write clearly in block capitals)SurnameFirst name(s)/Date of BirthGenderMaleFemaleNon-Binary or Gender Fluid/PLEASE ATTACH APHOTOGRAPH HERE IF YOUPrefer not to sayHAVE NEVER SUPPLIEDAddressONE TO US BEFORE, ORIF THERE HAS BEEN AMATERIAL CHANGE TOYOUR APPEARANCE (WRITEPostcodePhone numberYOUR NAME AND DATE OFBIRTH ON ITS REVERSE).MobileEmail addressNationalityPrevious licence number(Non-British passport holders MUST enclose proof of residency in the UK e.g. a utility bill or bank statement)EthnicityWhiteAsian or Asian BritishEthnic categories taken from GOV.UKMixed or multipleethnic groupsBlack, African, Caribbeanor Black BritishOther ethnic groupPrefer not to sayNationality and type of any other Competition Licence you holdSECTION 1B EMERGENCY CONTACT (Must be completed by all applicants)If you are under 18, please provide the details of a parent or legal guardian. For over 18s, please provide details for your emergency contact. Failure to complete thissection may delay your application.Full namePhone numberEmail addressIf your parent, legal guardian or emergency contact lives at a different address to you, please provide belowSECTION 1C HOW DID YOU USE YOUR LICENCE?Did you compete during 2021?YESNOIf ‘Yes’, please write the number of events you competed in next to each discipline below. If ‘No’, proceed to the next question below.AutocrossCross CountryKartingSprintAutotest / AutoSoloDrag RacingRallycrossTrialsCircuit RacingHill ClimbRallyingOtherWere you a member of a Club in 2021?YESNOIf ‘Yes’, please write the number of clubs you were a member oft: 44 (0) 1753 765050w: motorsportuk.org
SECTION 2A THE LICENCE(S) YOU NEEDTick the appropriate boxes to show the licence(s) you are applying for. Licences run from 1st January to 31st December of the year shown on the licence. If you are applyingfor more than one licence using this application form, you must pay the full fee of the most expensive licence, and then pay 50% of the fee for each additional licence.Note that the 50% discount for additional licence grades is only applicable when applying for both licence grades at the same time and does not apply to Entrant PG licences.INTERNATIONAL LICENCESRace Race International - ITA*Fee 1,193(If you are renewing, enclose proof that you havecompeted in at least one International Race in 2021)Race International - ITB*If you are renewing, enclose proof that you havecompeted in at least one International Race in 2021) 430Race International - ITC - C* 220Race International Truck - ITC - C* 220Race International - ITD - C* 220FeeRally and SpeedKart International Senior - ITE*ˇ 146Speed International - ITD - R* 220Kart International Restricted - ITF*ˇ 146Drag International IT DR* 220Kart International Junior - ITG*ˇ 146Off Road International - ITC - C* 220Cross Country International - ITC - R* 220Rally International - ITC - R* 228Kart * May require a medical or vision test, refer to section 4.ˇ If you are under 18 and competing in UK Nationalevents, your parent/legal guardian must completesection 2B. FeeNATIONAL LICENCESRace FeeKartIf you are under 18 your parent or legal guardian mustcomplete section 2B.Fee Rally and SpeedIf your are under 18 and competing in Drag racing yourparent or legal guardian must complete section 2B. FeeRace National* 155Kart National* 89RS National - Stage Rally 155Race National Truck* 155Kart Inter Club (UK Only)* 59RS National - Navigator 99Race Club* Formerly Race Inter Club(UK Only) 99Kart Inter Club (Valid Bambino Only) 59RS National - Drag 149Race Club* Formerly Race Inter ClubJunior Championship (UK Only)Kart Clubman (UK Only) 45RS National 149 99Kart Clubman Bambino (UK Only) 45RS Inter Club - Stage Rally (UK Only) 99RS Inter Club - Stage Rally Junior (UK Only) 99RS Inter Club (UK Only) 69* May require a medical or vision test, refer to section 4. Under 18s will require an Entrant PG licence issued totheir parent or legal guardian, complete section 2B.Are you going to be competingin Long Circuit Kart events?(If yes, Section 4 may need to be filled in. See H10.1.1)Need your licence in a hurry?Opt in for 3-day or 3-hour turnaround.FeeFeeOptions and totalsExpress Handling (3-hour) 115European Postage 12Express Handling (3-day) 65Rest of the World Postage 29Foreign ASN Authorisation Fee 48Options and totalsPlease allow 15 working days forthe processing of your licence(s).YES* NO (Post to UK is free of charge)SECTION 2B ENTRANT PG LICENCE DETAILS (For parent/legal guardian of under 18 Drag & Kart competitors only)Entrant PG Fee 25Parent’s surnamePARENT/LEGALPrevious PG Licence No. (if known)GUARDIAN PHOTOPLEASE ATTACH AParent’s first name(s)PHOTOGRAPH HERE IF YOUAddressHAVE NEVER SUPPLIEDONE TO US BEFORE, ORIF THERE HAS BEEN AMATERIAL CHANGE TOPostcodePhone numberYOUR APPEARANCE (WRITEMobileYOUR NAME AND DATE OFBIRTH ON ITS REVERSE).Email addressIf you have more than one child applying for a licence, please list their details below.Child 1Date of Birth//Child 2Date of Birth//Child 3Date of Birth//SOME OF OUR LICENCE HOLDER BENEFITS (Login to your member benefits portal for more details)Save money onthe full range ofWera ToolsFree personal accidentinsurance whilecompeting15% discount on roadcar insurance
SECTION 3 YOUR MEDICAL SELF-DECLARATIONMANDATORY FOR ALL APPLICANTS. All questions below MUST be answered by all competitors regardless of age and whether a medical is neededor not. Failure to complete this section may result in your application form being returned to you. In all cases if you answer YES please list andexplain. Please see points 2 and 10 in the declaration (section 6).1.Have you ever been refused or had any restrictions imposed on life assurance for medical reasons?2.Do you take, or have you recently taken any of the substances on the World Anti-Doping Agency prohibited list?(see H38 or www.wada-ama.org)3.Have you ever had a history of drug or alcohol abuse?4.Have you ever suffered with a severe allergic reaction, (requiring hospital treatment), or do you carry an EpiPen, or similar device?5.Have you ever been diagnosed with diabetes or treated with insulin or drugs to lower your blood sugar?6.Have you any history of any neurological disorder, including epilepsy, seizures, fits, dizziness, loss of balance, blackouts, faints,or any disorder where you may suffer loss of consciousness?7.Have you ever been diagnosed with obstructive sleep apnoea, or narcolepsy?8.Have you ever had any serious head injury resulting in loss of consciousness, or have you ever had concussion?9.Have you ever had a stroke, cerebrovascular accident or transient ischaemic attack (CVA or TIA)?10Have you ever been diagnosed with heart disease, or any heart disorder, including any arrythmia, angina, or high blood pressure(hypertension)?YESNO11. Have you ever had a heart attack (Myocardial Infarction) or had cardiac surgery such as a coronary artery bypass (CABG) orcardiac catheterisation for any reason?12. Do you take any anticoagulant drugs (excluding aspirin) to thin the blood e.g. Warfarin, Apixaban etc.?13. Do you have any implanted devices e.g. pacemaker, defibrillator etc.?14. Have you ever had any psychiatric illness or condition or mental disorder, including treatment for depression?15. Have you ever had any neurodevelopmental condition including Attention Deficit Hyperactivity Disorder (ADHD) or AutismSpectrum Disorder (ASD) e.g. Aspergers?16. Do you have any congenital abnormality of any limbs, amputation, or any other disability or any physical problem with, orpermanent difficulty in using your arms or legs for driving?17. Do you wear corrective lenses (contact lenses or glasses) for driving, including competition?18. Are you profoundly deaf and unable to hear?19. Have you ever had any operations or surgical procedures in the last 2 years?20. Have you been diagnosed with, or treated for any condition that you think may be relevant, or that may affect your ability tocontrol or get in and out of a vehicle?21. Please specify your Height and Weight: HeightcmWeightkgIf you have ticked ‘Yes’ toanything please providefurther details includingthe date of diagnosis /injury / surgery, and thetreatment / name of anymedication you receivedor are still receiving.SECTION 4 DO I NEED A VISION TEST OR DOCTOR’S MEDICAL REPORT?International LicencesDoctor’s Medical Report & Vision Test - Sections4A & 4BYour previous medical examination is valid for 12months and can be used to renew your licence,provided that your application is received andprocessed before the 12-month validity periodexpires. The expiry of the 12-month validityperiod must be beyond 1st January 2022.National, Club or Inter Club – Race, Truckor Long Circuit Kart LicencesMembers aged 14 – 59 years: Vision Test Only Section 4ARequired for members aged 14 to 44 yearsinclusive who have not previously supplied adoctor’s medical report. Required for membersaged 45 to 59 years inclusive who have not supplieda doctor’s medical report within the last 36 months.When upgrading from National to Internationallevel, the licence must be processed within3 months of a medical examination beingcompleted.Members aged 60 years and above: Doctor’sMedical Report & Vision Test – Sections 4A & 4BYou must have a medical and vision test at thefollowing age intervals: 60, 65, 70, 72 and 74 andannually from the age of 75.All medical examinations for International licencesmust include a vision test and be performed by adoctor registered to practice in the UK.If you have reached one of the above ageintervals since your last licence was issued, youmust have a medical and vision test.For all other licence grades a vision test or doctor’smedical report is NOT required. Please go to section 5.LICENCE HOLDER BENEFITFree vision test plus10% off eye care andcorrective surgery
SECTION 4A VISION TEST (For Race, Truck, Long Circuit Karting & ALL International Licences only. Refer to Section 4 for guidance)To be filled in by your doctor or optician.Vision – To be recorded in metric Snellen acuity:a.Uncorrected vision (without corrective lenses)Right eye: 6 /Left eye: 6 /b.Corrected (wearing corrective lenses if necessary)Right eye: 6 /Left eye: 6 /c.Vision with both eyes open, the minimum corrected visual acuity must be 6/6(wearing corrective lenses if necessary). See H10.1.10(a)d.Are corrective lenses (glasses or contact lenses) required for driving?YESNOe.Is there any ocular history that suggests the possibility of visual field loss? If ‘Yes’, give details below.YESNOf.Were there any abnormalities on the colour vision (Ishihara) test? If ‘Yes’, give details below. See H10.1.10(f)YESNOPlease use this space to give further details6 /Applicant’s nameSignature of optician/doctorDate//SECTION 4B DOCTOR’S MEDICAL REPORT (For Race, Truck, Long Circuit Karting & ALL International Licences only. Refer to Section 4 for guidance)1.Doctor’s namePlease read regulations 10.1.1 to 12.1.8 of the ‘What you need to knowabout your motorsport licence’ booklet (available in the Resource Centreof www.motorsportuk.org) before filling in this section for your patient,ensuring that ALL questions have been answered. Note that unansweredquestions will require further information to be submitted by you.1a. Doctor’s practice stamp/contact details including GMC registration no.1b. Applicant’s full name/Date of BirthHeight/cm Weightkg2.Are you the applicant’s registered General Practitioner? YES3.Is the 12 lead resting ECG normal? (A resting ECG is only required if the applicant is aged UNDER 45 AND applying for an International Licence)Applicants aged 45 or OVER who are applying for an International Licence must enclose a stress-related ECG report signed by a Consultant Cardiologist(see H11) or an accepted equivalent advised by a CardiologistNOBlood pressure/If no, in what capacity are you providing this report?N/A3a. When was the 12 lead resting ECG performed? (Note that a resting ECG is valid for a period of 24 months)YES/NO/The ‘normal’ answer to each question below is ‘NO’. In respect of each ‘YES’ response, further details should be provided in the doctor’s comments section.4.Is there any evidence of abnormality of the heart or cardiovascular system? If ‘Yes’, give details below.YESNO5.Is there any evidence of any mental condition in the applicant’s medical history? If ‘Yes’, give details below.YESNO6.Has the applicant suffered from epilepsy, seizures or any other neurological conditions? If ‘Yes’, give details below.YESNO7.Does the applicant have any physical condition or abnormality, or restriction of movement in the arms or legs? If ‘Yes’, give details below.YESNO8.Were any abnormalities found in the urine analysis? If ‘Yes’, give details below.YESNO9.Do you know of any reason why the applicant may be unfit to participate in motorsport? If ‘Yes’, please give details below.YESNOIf you have ticked ‘YES’ to any of the questions above, or if you are unsure of the applicant’s fitness to participate in motorsport activities and wish to refer the applicantfor further assessment to the Motorsport UK medical advisor, please give details below.Doctor’s commentsSign below to certify that you have examined the applicant in line with the ‘What you need to know about your motorsport licence’ booklet availablein the Resource Centre of www.motorsportuk.org.Your (doctor’s) signatureDate of medical examination//Please note: Your Competition Licence must be issued within 3 months of the date of having this medical examination. If your 2022 licence application is not submittedand processed within 3 months of the above date, the medical examination must be revalidated by the examining doctor before your licence(s) can be issued.
SOME OF OUR LICENCE HOLDER BENEFITS (Login to your member benefits portal online for more details)Discount on Tea& Coffee andfree shipping15% off competitioncar policies15% off bikes, accessoriesand nutritionSECTION 5 PAYMENT - PLEASE ADD YOUR TOTALS FROM SECTIONS 2A AND 2B Total Licence fee(s) Total other fee options Total Entrant PG Licence fee(s) Amount to be paid Credit or debit card (give card details below)*Cheque made payable to ‘Motorsport UK’Card numberExpiry dateCardholder’s name/Postal order made payable to ‘Motorsport UK’Phone numberCardholder’s signatureCardholder’s address*American Express and Visa Electron cards are not acceptedSECTION 6 DECLARATION, APPLICANT SIGNATURE AND PARENT/LEGAL GUARDIAN COUNTERSIGNATURE1. I understand and will comply with the ‘What you need to know about your motorsportlicence’ booklet which is available in the Resource Centre of www.motorsportuk.org.2. I confirm that the information given on this application form and any supportingdocumentation is true and complete. I have taken full responsibility for completingthe form and have not delegated any part of my responsibilities to any other person.If I provide false information I understand that I may face financial penalties andMotorsport UK may take disciplinary action against me, which may lead to mylicence being permanently withdrawn. Failure to complete the form accurately withfull disclosure may void insurance cover.3. I will not do anything that could damage the reputation of or have any negativeeffect on motorsport generally. I understand that if I do so, Motorsport UK maytake disciplinary and/or other action against me (see General Regulations A.2.2.1.3,2.2.1.4, H.3.1.2 and H.6).4. I undertake for the purpose of this application to never make use of drugs or ofprohibited methods such as are defined in the Prohibited List of the World AntiDoping Code of the WADA and by the Anti-Doping regulations of the FIA (see H38or www.wada-ama.org) and understand if I do so, that Motorsport UK will takedisciplinary action against me and my licence is likely to be permanently withdrawn.5. Motorsport UK operates a zero tolerance policy to the use of drugs and alcohol and Itherefore confirm that I will not take part in any practice or competition while underthe influence of drugs or alcohol and understand if I do so, that Motorsport UKwill take disciplinary action against me and my licence is likely to be permanentlywithdrawn. I agree to submit to all testing protocols required.6. I confirm that the information given to the examining doctor regarding my presentstate of health and previous medical history is correct to the best of my belief.7. I agree to Motorsport UK’s Medical Consultant obtaining medical reports (ifrequired) from any doctor who has ever seen me about anything which affects myphysical or mental health. I have read General Regulation H.9.2 setting out myrights and the procedures for dealing with medical reports.8. I understand that if any medical conditions arise during the validity of my licence,including (but not limited to) accidents at motorsport events, I must informMotorsport UK’s Medical Administrator prior to competing in any further motorsportevents. I shall conform to all applicable COVID-19 protocols.9. Where a medical report is provided by a doctor other than your own registeredGeneral Practitioner, we may ask for confirmation from your own GP. Whereadditional or specialist medical reports are deemed necessary, or clarification isrequired, this may result in a delay in your application. You should not commit toentering any event until your application has been approved.10. I understand Motorsport UK needs to collect, process and retain personalinformation about me including medical details contained in this applicationin order to issue my licence and to perform its obligations under the GeneralRegulations, in accordance with its Data Protection Policy found at www.motorsportuk.org/data-protection or by contacting us at [email protected]. I also understand Motorsport UK would like to use such information for thepurposes, as specified in its current Data Protection Policy, which I have read andunderstood.11. A competitor shall not have time off school to participate in motorsport without theprior written approval of their school (see H7.1).12. I understand that any Competition Licence issued will remain the property ofMotorsport UK which reserves the right to withdraw or suspend it at any time. Thereason(s) for any withdrawal or suspension shall be stated (see H3.1.2).13. I hereby consent to the collection, safe processing and retention of my current andfuture medical data, obtained by Motorsport UK, in pursuance of its obligations asthe authorised national sporting authority.14. Motorsport UK is committed to making positive progress in our Equality, Diversity& Inclusion programmes and therefore wishes to collect additional member dataregarding ethnicity, disability and gender identity to establish clear baselines ofthe members of our community. This data will be treated as confidential and inaccordance with the UK GDPR & DPA 2018 and will be used for statistical purposesonly with access restricted to staff involved in processing and monitoring the data.If you do not wish to provide this information please use the option of “prefernot to say”. Erasure of this data can be requested at anytime in line with our dataprotection policy which can be found at www.motorsportuk.org/data-protection.15. I will comply with the Motorsport UK Respect Code and understand that breachingthe obligations may result in disciplinary action. The Motorsport UK Respect Code isavailable to view at motorsportuk.org/racewithrespect.Part 1Applicant’s signaturePart 2 (If under 18)Parent or legal guardian’s signaturePart 3 (If also applying for an Entrant PG licence)Parent or legal guardian’s signatureApplicant’s name (block capitals)Parent or legal guardian’s name (block capitals)Parent or legal guardian’s name (block capitals)DateDateDate/(The parent/legal guardian consents to agreement onbehalf of the individual by way of their signature below)/////
SECTION 7 CHECKLISTTo avoid any unnecessary delays in issuing your licence (which may result in your application being returned) please use the below checklist to ensure you havecompleted the application form correctly.I understand and will comply with the ‘What you need to know about yourmotorsport licence’ booklet which is available in the Resource Centre ofwww.motorsportuk.orgI have enclosed the correct payment: Cheque/Postal Order orCredit/Debit card details in Section 5.I have signed and dated the declaration in Section 6 above.My parent/legal guardian has also countersigned in Part 2 if I am under 18.I have entered any changes to my personal information in Section 1A.I have completed Section 3 (this is mandatory and MUST be completed byALL applicants).N/AN/AMy doctor/optician has completed Section 4A (if applicable,see Section 4)My doctor has completed Section 4B (if applicable, see Section 4)N/AMy doctor has provided any additional medical information I needand this is attached.N/AN/AI have attached a passport style photograph with my name and dateof birth on the reverse.If I am not a British Passport holder, I have requested authorisationfrom my home ASN prior to submitting my application, or I have encloseda utility bill showing my name and UK address and have paid the ForeignASN Authorisation Fee in Section 2 (Options and totals) and I would likeMotorsport UK to request the authorisation on my behalf.SOME OF OUR LICENCE HOLDER BENEFITS (Login to your member benefits portal for more details)Plus discounts and offers from all these great brands and more.20% off motorsportmedicalsFree consultation andcompetitive ratesDiscounted range ofcompetition seats10% off helmetsDiscount oncompetition tyresSave money onbreakdown coverTHANK YOU FORYOUR APPLICATIONWe hope you have a great year inmotorsport. Please visit our website atmotorsportuk.org/Events/Find-Events tofind out more about upcoming events in 2022.In the event of an accident, Motorsport UK may share your informationwith the FIA Motor Sport World Accident Database. To opt in pleasetick here.Please return this form, your payment and any additional information youhave to provide to:Motorsport UK, Bicester Motion, OX27 8FYIf you would like to receive information from carefully selectedorganisations and partners other than Motorsport UK and its memberclubs via postal or electronic means, please tick the box.Motorsport UK Association Limited trading as Motorsport UK.Registered in England and Wales with Company Number 1344829.Registered Office: 141 The Command Works, Southern Avenue,Bicester Heritage, OX27 8FYt: 44 (0) 1753 765050w: motorsportuk.orgOurMotorsportUK
Express Handling (3-hour) 115 Express Handling (3-day) 65 Kart If you are under 18 your parent or legal guardian must complete section 2B. 9 Kart National* 89 Kart Inter Club (UK Only)* 59 Kart Inter Club (Valid Bambino Only) 59 Kart Clubman (UK Only) 45 Kart Clu
