REGISTRATION FORM
for printing
Last name :
.....................................
First name
:
.................................
Adress
:
..............................
Postal code:
City:
.............................................
Phone
:
Fax :
E-mail :
......
Motorcycle type :
 required! n° immat ou n° chassis ou n° moteur
:
Driving
license #
.or
CASM #
Insurance
Company
contrat
#
.
or
licence # for this year
..
Steering
level : (......)
beginner (......)
medium (......)
pilot
(Chrono at LEDENON: ........................ or Chrono at BRESSE: ........................)
Wishes
to participate in the day or weekend::
on
2010 at
(circuit)
I enclose payment by check to: ACTIVBIKE in the amount of
euros.
Consider joining your mailing photocopies of your insurance or your motorcycle license and driver's license in order to save time and ease of administration on the spot.
Noise level
- BRESSE: 95dB 60% of the max,
- DIJON PRENOIS: 102dB,
- BOURBONNAIS: 102dB.
At
............................................................ the
.............................................
Signature :
IMPORTANT
also to meet discharge
send to : ACTIVBIKE ROUSSEL Nicolas 8 lot les Tillières 71480 DOMMARTIN LES CUISEAUX
Tel : 03 85 76 65 90 / 06 82 33 81 03
E-mail : activbike@wanadoo.fr
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