VMXSA Terra Topia National - Entry Form

Official news from VMX SA

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VMXSA Terra Topia National - Entry Form

Postby VMXSA » Mon Aug 12, 2013 2:53 pm







Fax: 086-539-8616 Tel: 082-928-3363 email: vmxsa@live.co.za





OFFICIAL ENTRY FORM

























































































Class





Indicate





Class





Indicate





Class





Indicate





Class





Indicate





1. Pre75









2. Pre80









3. Pre85 A









4. Pre85 B









5. Pre90









6. 125cc









7. 250cc









8. 500 cc









9. Vets (<45)









9. Master (>40)









10. 125 Two stroke









11. Open Two Stroke











































































Date









Race #









Name









WOMZA License #









Postal Address









Phone #









Mobile #









Email









Fax #





































































Make





Model





Capacity



























































Name of registered club you

belong to:













Bank Details: V.M.X.S.A, Standard Bank, Bedford

Gardens, Branch code #: 018305, Acc #: 240252209













Declaration / Undertaking,

to be signed by every competitor





I have read and understand WOMZA

General Competition Rules 2013 and signify my/our agreement to abide by these

rules by signing this entry form. I, the

lawful parent/guardian of the above-mentioned competitor, do hereby grant

permission for him/her to ride in the above-mentioned event. If a competitor is a minor, this form must be

countersigned by the appropriate parent or guardian.









Date: 2482013 Permit

#:









Rider:













Official Use









Licence Type: Social Club Region National









Licence #: Medical Cover: WOMZA/ Private









Medical Aid Company name Medical Aid #:









Amount due:









Official Signature: Paid by:

R400 Cash / Cheque / EFT





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