Invitation

Entryform

31th HORSEPOWERRUN

April 22th 2011

 

First name:

Birthdate:

Postalcode:

Phone:

Address:

Town:

E-mail:

Family name:

Mr.

Mrs.

Tricycle

Forecar

Solo

Sidecar

Motor details:

Make:

Capacity:

Year of manufacture:

Frame number.:

Model:

HP:

Reg. number:

Pioneercert.nr..:

I would like a one-day insurancecover of € 5,-

The entrance fee of € 20,00 is transferred onto RABObank

account no. 34 72 37 584 of Stichting HORSEPOWERRUN Norg

IBAN nr. NL79 RABO 0347 2375 84      BIC nr. RABONL2U

Attention; Payment on the day of the Run will be: € 25,00

Additional information regarding the machine and/or questions for the organisation:

This form has to be filled out, printed and send to:

 

Secretariaat HPR

p/a Stephanie van Kessel

Hoofdweg 19

9341 BG   Veenhuizen

 

Date: ………………..                              Signature:………………………...