MSZ COMPETITION LICENCE APPLICATION FORM

Please call (024)2746712 or 0777472907 should you require assistance. This form must be completed by persons over 18 years of age. If applicant is under the age of 18 it must be completed by a person in the capacity of parent/guardian/curator, giving details of competitor. Parent/guardian/curator to complete section at foot of the form

If medical has expired – medical forms can be downloaded from documents. Please scan and email the completed form back to officemzim@zol.co.zw

New / Renewal

New Renewal

Surname

First Name

Date of Birth

Place of Birth

ID Number

Nationality

Residential Address

Cell

Name of Medical Insurance

Medical Aid Number

Doctor

Doctor's Address

Name of Club

Club Membership Number

Previous License Number

Type of Previous Licence

National Restricted

Type of Licence Required

Motor Racing Motorcycle Road Racing Karting Motocross Enduro Flat Track/Oval Drags Other

Grade of Licence Required

Senior Junior

Grade of Licence Required

International National Restricted Other

I shall pay my licence fee via
(Banking details: Motorsport Zimbabwe, Stanbic Bank, Msasa Branch, Acc No. 914 000 307 2702)

EFT Cash Cash deposit

Paid? Once you have paid please send your proof of payment to officezmsf@zol.co.zw

Yes No

Blood Group

Have you been prohibited from participating in ANY motorsport on medical grounds in the last five years

Yes No

If yes, please provide details

Do you suffer from any ailments that would impair your ability to compete safely in motorsport?

Yes No

If yes, please provide details of impairments

Do you suffer from any of the following?

Loss of vision in one eye/impaired vision not corrected by lenses Deafness in both ears with no balance problem Head injury or concussion Uncontrolled hypertension Drug or Alcohol abuse/use of banned substances (WADA) Asthma or other lung disease Bone or joint injury or disease Epilepsy and/or convulsions Recurrent dizziness or headache Kidney problems Type 1/Type 2 Diabetes with complications Gastro intestinal disorders Allergy to medication or other substance Blood disorder or bleeding tendancies Do you take prescription medication Heart or heart valve problems Controlled cardiac arrythmias Recent cardiac surgery/arterial disease Traumatic amputation of a limb Emotional/mental nervous disorder Recent transplantation Current/recent chemotherapy or radiation therapy Paraplegia or co-drivers Hospitalisation in the past year None of the above

If yes to any of the above, please give details

I have read and agree to be bound by the General Competition Rules and any subsequent regulations of Motorsport Zimbabwe (MSZ). I agree that neither MSZ nor the promoter, organiser, guarantor and/or sponsor of any competitions or the owner/s of property on which a competition is held, or the Government, Council or Municipal body, and their respective officials, agents, servants or representatives shall in any circumstances whatever, be liable for any damage done to or done by any vehicle entered by or ridden in or attended by me in any competition or for any personal injury, fatal or otherwise, or loss of whatever kind sustained by myself or by any person riding or attending upon it or any person whatsoever, whether caused during any competition or any practice run or while the said vehicle is on any road or area forming part of the track or route, or any deviation therefrom or any approach by whatever means such damage, injury or loss may be caused, and even though the same may be contributed to or caused by the willful act, neglect or default of any official agent, servant or representative of the MSZ, or any promoter, organiser, guarantor or sponsor of the competition, or the owner/s of the property on which the competition is held, or any Government, Council or Municipal body

Agree

I hereby indemnify MSZ, the promoter, organiser, guarantor and sponsor of the the competiton and the owner/s of any property on which the competition is held and any Government, Council and Municipal body and their respective officials, agents or servants and representatives against any legal liability for any damage or injury or the loss so done or sustained as aforesaid by myself or any other such persons as aforesaid. I further declare that I am aware of the risks, dangers and perils attendant upons motor car racing and/or motorcycle racing or any other form of motoring competition, which I hereby assume. This indemnity shall apply to all competitions (held under the authority of a permit issued by MSZ, or for which a waiver from the need for hlding such a permit has been granted by MSZ), in which I take part in any capacity whilst I am the holder of any competition licence issued to me by the MSZ, or their successors in title, in accordance with the General Competition Rules of MSZ.

Agree

In accordance with the protocols of the FIA and FIM Anti-Doping Codes, I am aware that I may be tested for prohibited substance both during and out of competition. I accept and understand that should I rest positive on the samples submitted that I will be subject to discriplinary action as envisaged in the Anti-Doping Codes as prescribed by WADA, the FIA and FIM. I accept and understand that I am liable for all third party repercussion.

Agree

I certify that I am physically and psychologically fit to take part in all categories of motor sport. I am aware of the dangers of motor sport and the potential danger to others by ay action on my part. I am aware that any false declaration will result in my competition licence being revoked with immediate effect, and could result in legal action being taken against me should third party claims arise as a result whilst competing in motor sport, and that any claim made against MSZ insurers will be rejected.

Agree

Today's Date

For Applicants under 18 years of age

Parent Guardian Curator

Full Name

I hereby consent to the participation of my son/daughter/ward in any form of motor sport controlled by MSZ, and for which the said MSZ has issued a valid competition licence to my said son/daughter/ward. I further agree that this form of consent be read as part and parcel of and together with the above Form of Indemnity which I have also completed and agree to, the contents of which are fully understood by me and my son/daughter/ward. I hereby acknowledge that I am full conversant with, and hereby assume the risks, dangers and perils of motor sport participation wherein is allowed by the issue of a competition licence by MSZ.

Agree

Competition License Application

MSZ COMPETITION LICENCE APPLICATION FORM

If medical has expired – medical forms can be downloaded from documents. Please scan and email the completed form back to officemzim@zol.co.zw