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Subscription FORM "GiroSardegna" (22-29 apr 2012) (Each form should contain the data for the occupants of only one room in the hotel)
Complete and send before 29/02/2012 to: MARE& MONTI - Via Mar Ligure 96 - Loc. Flumini - 09046 Quartu S.E. (CA) | fax: 070898226 | mail: info@girosardegna.it (Indicate the group as it should be referred to in the Giro _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ or the family beside whom you wish to be accommodated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ) | |
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Indicate the type of participant for each person:
Accommodation in Hotel (mark with X) :Yes(_) No(_) | hotel Option : -Cala Ginepro-A1(_) A2(_) -Giardini di C.Ginepro-A3(_) A4(_) -Torre Moresca-A5(_) A6(_)GG=GranGiro; MG=MedioGiro; T=Tour; kM=1000km; Gbs=GiroSmeraldo; GbM=GiroMuflone; Acc=Accompagnat; Inf=0-2 anni; Bam=2/6 anni; Rag=6/12 anni Supplements: single person (_) | two-room suite (_) | extra days half-board at Golfo Aranci(_)/at Cala Ginepro(_): 18/4(_) 19/4(_) 20/4(_) 21/4(_) | 29/4(_) 30/4(_)
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Surname/Name resident in Postcode Town Country 1°___________________________________ ____________________________ ________ ____________ ____ Tel.__________ Fax . . . Cell_______________ E-mail__________________________ Cycling club ________________________ Sex (M/F) ___ Date of birth . . . . Specific Costs:Basic Hotel ______ +2 room Suite _____+single person _____ +extra days ______+Race entry _____ = Total . . . . | Indicate participation GG(_) MG(_) Tour(_) GbS(_) GbM(_) KM(_) Acc(_)Inf(_)Bam(_)Rag(_) |
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Surname/Name resident in Postcode Town Country 2°___________________________________ ____________________________ ________ ____________ ____ Tel.__________ Fax . . . . Cell_______________ E-mail__________________________ Specific Costs : Basic Hotel ______ + extra days ______ + Race entry ______ = Total . . . . | Indicate participation GG(_) MG(_) Tour(_) GbS(_) GbM(_) KM(_) Acc(_)Inf(_)Bam(_)Rag(_) |
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Surname/Name resident in Postcode Town Country 3°___________________________________ ____________________________ ________ ____________ ____ Tel._________ Fax . . . . Cell_______________ E-mail__________________________ Cycling club _______________________ Sex (M/F) ___ Date of birth . . . . Specific Costs : Basic Hotel ______ + extra days ______ + Race entry ______ = Total . . . . | Indicate participation GG(_) MG(_) Tour(_) GbS(_) GbM(_) KM(_) Acc(_)Inf(_)Bam(_)Rag(_) |
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Surname/Name resident in Postcode Town Country 4°___________________________________ ____________________________ ________ ____________ ____ Tel._________ Fax . . . . Cell_______________ E-mail__________________________ Cycling club _______________________ Sex (M/F) ___ Date of birthl . . . . Specific Costs :Basic Hotel ______ + extra days ______ + Race entry ______ = Total . . . . | Indicate participation GG(_) MG(_) Tour(_) GbS(_) GbM(_) KM(_) Acc(_)Inf(_)Bam(_)Rag(_) |
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Total cost to be paid for the room __________ ; Payments made: € ______ dated __________; € _______ dated __________ ( ) to postal account n.22191092 owned by Mare & Monti -Via Mar Ligure, 96 - 09046 Quartu S.E. (CA)
( ) to bank account n. 17357.75 owned by Mare & Monti presso il Monte dei Paschi di Siena - Sede di Cagliari code: IT 74 N 01030 04800 000001735775; code BIC: PASCITMMCAG ( ) by another method (indicate which) _ _ _ _ _ _ _ _ _ _ _ | Method
of payment made (please attach the receipt) |
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I, the undersigned, in my capacity requesting the subscription to the "GiroSardegna" or as the President of the Sporting Club referred to,
declare that the data above correspond to the truth. In relation to the privacy law n.675/96, I consent to the use, by the organising Association,
of the personal data detailed above for the carrying out of their activities.
I recognise that the treatment of the data will be made using tools which guarantee the security and privacy and can be also made using automatic tools to store, manage and transmit the data. Also, I declare for myself and the other cyclists that we are aware of and shall abide by the rules of the event; that the cyclists detailed above are fit physically and trained; that the cyclists subscribe voluntarily and assume all the risks associated with the participation in a cycling event. Therefore, I free the organising Association of all responsibilities, known and unknown, deriving from the said event. I authorise the publication of anything referring to the event in newspapers, magazines, videos and television broadcasts and on the internet. Date of subscription __________________ Signed__________________________________ | |