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General Vehicle data |
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Make/brand
Year Made
Chassis/Frame No.
Where is the chassis/frame number on the vehicle
:
Registration (number plate) No.
Country of registration:
Vehicle length (cm)
Vehicle width (cm)
Vehicle height (cm)
Vehicle Weight (Kg)
Please shortly describe the history of the vehicle:
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Body/Frame details |
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Body/frame type
Body/frame made by
Year Made
Colour(s)
Vehicle still has the original
body: Yes
No
if not:
Is the body to original specification; Yes
No
Please describe the changes
to the body
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Interior & Instrumentation details |
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Number of seats
Interior still original: Yes
No
if not:
Please describe the changes
to the interior
Is the instrumentation still original: Yes
No
if not:
Please describe the changes
to the instrumentation
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Chassis/frame, breaks and steering details |
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Is the chassis/frame still original: Yes
No
if not:
Is the chassis/frame to original specification; Yes
No
Please describe the changes
to the chassis /frame:
Is the front axle still original: Yes
No
Track width front
if not:
Is the front axle to original specification; Yes
No
Please describe the changes
to the front axle
Is the rear axle still original: Yes
No
Track width rear
if not:
Is the rear axle to original specification; Yes
No
Please describe the changes
to the rear axle
Is the final drive still original: Yes
No
if not:
Is the final drive to original specification; Yes
No
Please describe the changes
to the final drive
Vehicle wheel base (cm)
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Brake system
Are the breaks to original specification; Yes
No
if not:
Please describe the changes
to the breaks
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Hydraulic, cables, compressed air, etc. |
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Original steering system
Is the steering system to original specification; Yes
No
if not:
Please describe the changes
to the steering system
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Rack & Pinion, recirculating ball, cables, etc. |
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Wheels, Tires ad Lighting system |
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Wheel size
Wheel type
Wheel size front
Wheel size rear
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Lighting System
Is the lighting system to original specification; Yes
No
if not:
Please describe the changes
to the lighting system
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Carbide, electrical, gas, etc. |
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Engine, Gearbox, etc. |
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Engine Make
Engine number
No. of Cylinders
Capacity (cm3)
Bore (mm)
Stroke (mm)
Horsepower
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Is the engine original; Yes
No
if not:
Is the engine to original specification; Yes
No
Please describe the changes to the engine:
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Ignition System
Is the Ignition system to original specification; Yes
No
if not:
Please describe the changes
to the Ignition system
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Coil, Magneto, diesel, etc. |
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Fuel System
Carburetor make
Carburetor type
Number of carburetor(s)
Is the Fuel system to original specification; Yes
No
if not:
Please describe the changes
to the Fuel system
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Gearbox type
Number of gears
Is the gear box the original one; Yes
No
if not:
Is the gear box to original specification; Yes
No
Please describe the changes
to the gear box
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Hand, automatic, pre-selector, etc. |
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Owner Data:
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Owner Data: |
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Mr.
Ms.
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Title
Given name
Last name
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Birth date
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DD/MM/YYY |
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Address |
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Address
Postal code
State
City
Country:
Phone Number
email address
Member of vehicle club 1
Member of vehicle club 2
Member of vehicle club 3
Date of application
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DD/MM/YYY |
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