The Federation of Motor Sports Clubs of India
A-25, Krishna Towers, 50 Sardar Patel Road, Chennai - 600113
Phone: (91) (44) 22352673 Fax: 22351684
Email: firstname.lastname@example.org Web: www.fmsci.co.in
Two Stamp Size PhotographsRequisite License FeesXerox copy of Civil Driving License (self attested – Signed). Do not send Original CDL
Stress Test (TMT) and ECG Report
Endorsement from FMSCI Member Club / recognized team with their seal and signature on the first page of the application form or certificate from approved training school
Two Stamp Size PhotographsRequisite License FeesProof of age (Xerox of Birth Certificate, Passport etc. self attested)
FMSCI Member Club / Recognized Team seal and signature on the first page of application form or certificate from approved training school.
CHEQUES NOT ACCEPTED.
Demand Draft in favour of “The Federation of Motor Sports Clubs of India”, payable at ChennaiNEFT Transfer. Account Holder : The Federation of Motor Sports Clubs of India, SB Account No.801010100003491, Bank : Bank of India, Adyar Branch, Chennai 600020, IFSC : BKID0008010Screen shot of NEFT Transfer with UTR number
Date of Birth:*
Allergy (if any):
Civil Driving License No.:*
Address for communication:*
Landline Number (With STD Code):*
Name of contact Person in case of emergency:*
I have read and acquainted myself with the National Competition Rules (NCR) of the FMSCI. I agree to submit myself without reserve, to the jurisdiction of the FMSCI in respect of its control and regulation of motor sports in India. I renounce the right to agitate, litigate or otherwise seek legal redress, until after exhausting the provisions of protests and appeals as laid down in the NCR under pain of disqualification. I agree that grant of the competition license is a privilege granted to me by the FMSCI and agree to return it to the FMSCI on demand. I hereby promise to produce my original Civil Driving License, FMSCI competition license and Medical Certificate on demand to any FMSCI official authorised to call for the same.
Loss of consciousness for any reason, dizziness or headache:
Details to be given if not normal:
Eye sight normal in both eyes (with spectacles if usually worn):
Allergy to medicines or drugs:
Diabetes (if yes, do you take insulin or oral diabetic tablets):
Blood pressure disorder:
Stomach problems (ulcer, etc):
Epilepsy or convulsions:
Mental or nervous disorder:
Problems with arms or legs including muscle cramp or joint stiffness:
Blood disorder with tendency to bleeding:
Do you take medicine or drugs regularly ?:
Have you been rejected, or accepted at increased premium for life insurance on medical grounds ?:
I have not been banned, on medical grounds, from taking part in any other sportI do not take drugs and do not abuse alcoholIn case of an injury I give permission to the Medical Staff to release any relevant information to the Clerk of the Course and the FMSCII declare that the information that I have given is the truthI agree to the information on the Medical Examination form being sent to the Doctor of FMSCI
Note: The act of submitting this certificate for a motorsport license is deemed to be a formal declaration by its holder that he / she, since its issue, has suffered no illness or injury which might be liable to affect its validity.
This is to certify that I, the undersigned, submit this application for an FMSCI Competition Licence. I hereby agree to indemnify the associations known as the FIA, FIM, FMSCI, its affiliated clubs, all sponsors and all or any members, officials or assistants of any of the above named and/or known organisations against injury or accident to myself or damage to my equipment, whether in practice or competition. I undertake to be bound by the rules issued by the FMSCI now and in the future and to any Supplementary Regulations which apply. I further certify that the competitor is medically fit to take part in motorsport events. I certify that the information / enclosures submitted with the application form, to the best of my knowledge and belief, true, complete and correct in every particular. I agree that any Competition Licence issued is the exclusive property of the FMSCI. Only the FMSCI, as the National Sports Federation of the Government of India, has the power to grant or withdraw it and to settle any disputes that may arise from its use. By signing this form, I certify that I, shall not participate in any event deemed unauthorised by the FMSCI with this license. Finally, I hereby acknowledge that I am fully conversant with the risk and dangers of motor sports in general which I assume hereby.
I DO HEREBY FURTHER AGREE to keep save harmless and keep indemnified the Central and State Governments, the organisers and their respective officials, representatives, sponsors, employees, agents and all persons assisting them in this event from and against all actions, claims, cost, expenses and demands –