Online Registration

SECTION A -- Driver Information

Fill in all pertinent data:

1. What is your first name?
   
   
   
   What is your last (family) name?
   
   
   
   What is your Nationality?
   
   
   
   
2. What is your mailing address?

   Street       
                      
   City           
   State              Province  
   Zip Code  Country  
   

3. What is your phone number?
   
   
   
   

4. What is your fax number?
   
   
   
   

5. What is your e-mail address?
   
   
   
   

6. Have you registered for the 12th ICCCR already?
   
   Yes   No 
   

7. Do you belong to a Citroen/Panhard Club?
   
   Yes   No 
   

8. If yes, which Club?
   
   
   

9. Where will you start the Raid?
   
   Rocklin, CA (North) Barstow, CA (South) Other (list connection point in comments below) 

10. Can you volunteer to help at the 12th ICCCR?
    
    Yes   No

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SECTION B -- Other Participants

Fill in all pertinent data:

1. Additional participant #1
   Name: Nationality: Check box if under 18 years of age
   
   
2. Additional participant #2
   Name: Nationality: Check box if under 18 years of age
   
   
3. Additional participant #3
   Name: Nationality: Check box if under 18 years of age
   
   
4. Additional participant #4
   Name: Nationality: Check box if under 18 years of age
   
   

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SECTION C -- Vehicle Information

These are the instructions for filling out this section. These are the instructions for filling out this section. These are the instructions for filling out this section.

1. What model Citroen will you travel in?
   
   2CV Other A-Series Traction Avant H-Van DS SM CX Other Citroen
   
   
2. If you selected "Other" please list specific model:
   
   
   
   
3. What year is your Citroen?
   
   
   
   
4. What State or Country is your Citroen registered in?
   
   
   
   
5. What is your Citroen's license plate number?
   
   
   
6. Please enter any additional comments:
   
   
   
   Check the Main Web page often for updates! http://www.designmassif.com/mad-dash

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SUBMISSION

Thank you for taking the time to answer the questions.

After you press the SUBMIT button, you will need to initiate a Send-and-Receive cycle of your e-mail client program which will send us the information you have entered.

DON'T FORGET - you will need to print and sign and fax the RULES OF THE RAID form to (916) 689-3928 as well as send in your Registration fee to finish the registration process.

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