Professional Documents
Culture Documents
A-25,
25, Krishna Towers, 50 Sardar Patel Road, Chennai 600113
Ph : (91) (44) 22352673 Fax : 22351684
Email : admin@fmsci.in Web : www.fmsci.co.in
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All licenses are valid till 31st December of year of issue.
Must possess Individual Entrant License or Team Entrant License to take part in Karting
Clubsport Karting License is valid only for events up to and including Open status.
Incomplete forms will be rejected
You may check the status
us of your competition license in www.fmsci.in/license after
submitting the application form.
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ClubSport
(Valid only for events upto
and including Open Status)
4W KARTING DRIVER
Cadet National
( 7 years to 12 years must
celebrate at least 7th
birthday in 2016)
Regular National
( 13 years and above
must celebrate at least 13th
birthday in 2016)
Date of Birth
(dd/mm/yyyy)
Foreigner (Y/N)
Blood Group
Allergy
Sex
Expiry Date
(dd/mm/yyyy)
City
Pin Code
Mobile Number
Email
Name of contact Person in case of emergency
Relationship
Mobile Number
Date :
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(TO
TO BE FILLED BY THE APPLICAN
APPLICANT)
Competitor
No
Yes
Date :
Signature of the Applicant
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The following general principles apply in passing a competitor as fit to race / rally despite a physical disability. He
must not have more than one main disability. If his hand or arms are affected he must still have effective use of
both hands in steering. He must not be a diabetic, or suffer from any of the conditions requiring
requiring treatment for the
maintenance of physical stability. Applications with impaired or no vision in one eye may be allowed to race
provided that they had this disability for not less than five years and have satisfactory judgement of speeds and
distance.
e. In addition, vision in the remaining eye must reach a standard of not less than 6/6 corrected by the
wearing of glasses if necessary. Should a Doctor not approve an applicant, on no account should he sign the
Declaration below. But instead send this form to the FMSCI with his observations, recommending whether or not
the FMSCI Medical Panel should examine the applicant. Any fee charged for completion of this certificate or the
examinations associated with it is the responsibility
responsibili of the applicant NOT the FMSCI.
Competitor
Normal
Cardio-vascular system
Blood Pressure
Pulse
Respiratory system
Nervous System
Central
Peripheral
Ear, Nose & Throat, in particular vestibule cochlear
Right
Left
Locomotor System
Right Arm
Left Arm
Right Leg
Left Leg
Spine
Abdomen (Hernia)
Urine
Albumen
Glucose
Eyes Distant Vision With / Without Correction
Right
Left
Color Vision (for Red, Yellow and Blue)
Right
Left
I, the undersigned certify that in respect of motorsport, this competitor
is fit to take part
is NOT fit to take part
be examined by FMSCI Medical Panel
Doctors Name
Qualification
Date
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Regn. No.
Seal & Signature
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Date :
Place :
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