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ENTRANCE FORM - 23 to 30 April 2011 -"GiroSardegna" (23-30 apr 2011)
Send before 31/12/10 (with the reduced hotel price) or 26/02/11 (full price) to: MARE & MONTI Via Mar Ligure 96 - Loc. Flumini - 09046 Quartu S.E. (CA) - fax: 070898226 - mail: info@girosardegna.it or to peteranne@peteranne.it N.B.- Each form should contain the details of the occupants of only one hotel room
Group reference for the participants of the GiroSardegna:_________________________ |
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Type of partipant ( indicate with X )
GG=GranGiro; MG=MedioGiro; T=Tour; kM=1000km; Acc=Companion; Inf=0-2 years; Bam=2/6 y.; Rag=6/12 y. |
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Surname/Name Sex Date Size Chip Code______________
(M/F) of birth (XS/…/XL) 1°____________________________ ___ ______ _____ (GG) (MG) (T) (kM) (Acc) (Inf) (Bam) (Rag) Address _________________________________________ Tel.____________ Fax___________ Cell _______________ E-mail ___________________________ Sports Club _______________ |
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Surname/Name Sex Date Size Chip Code______________
(M/F) of birth (XS/…/XL) 2°____________________________ ___ ______ _____ (GG) (MG) (T) (kM) (Acc) (Inf) (Bam) (Rag) Address _________________________________________ Tel.____________ Fax___________ Cell _______________ E-mail ___________________________ Sports Club _______________ |
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Surname/Name Sex Date Size Chip Code______________
(M/F) of birth (XS/…/XL) 3°____________________________ ___ ______ _____ (GG) (MG) (T) (kM) (Acc) (Inf) (Bam) (Rag) Address _________________________________________ Tel.____________ Fax___________ Cell _______________ E-mail ___________________________ Sports Club _______________ |
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Surname/Name Sex Date Size Chip Code______________
(M/F) of birth (XS/…/XL) 4°____________________________ ___ ______ _____ (GG) (MG) (T) (kM) (Acc) (Inf) (Bam) (Rag) Address _________________________________________ Tel.____________ Fax___________ Cell _______________ E-mail ___________________________ Sports Club _______________ |
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Hotel Y(_) N(_) (mark an X for the chosen option)
4 star Hotel preferred: A0(_), A1(_), A2(_), A3(_), A4(_), A5(_), A6(_), O1(_), O2(_) 3 or 2 star hotel preferred: A7(_), A8(_), A9(_) Supplements - single room (_) – extra hotel nights: 20/4 (_) 21/4 (_) 22/4(_) – 30/4(_) 01/5(_) |
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Surname Hotel (23-30/4)
(extra) (single) Race Discount Total
1° _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______ _______ _______ ______ ______ ______ 2° _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______ _______ _______ ______ ______ ______ 3° _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______ _______ _______ ______ ______ ______ 4° _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______ _______ _______ ______ ______ ______ Total to be sent ____________
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Payment: € _______ made _____________; € ________ made _____________
Method of payment made ( please attach the receipt ):
( ) post office account n.22191092 in the name of Mare & Monti -Via Mar Ligure, 96 – 09046 Quartu S.E. (CA)
( ) current bank account n. 17357.75 in the name of Mare & Monti at il Monte dei Paschi di Siena – Cagliari office, IBAN code: IT 74 N 01030 04800 000001735775; code BIC: PASCITMMCAG ( ) other (indicate method) _ _ _ _ _ _ _ _ _ _ _ |
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The undersigned either as those requesting booking in the "GiroSardegna" or as President of the relevant Sports Club, declare that the data provided above represents the truth. In relation to Italian law n.675/96, I express my consent to the use of our personal data by the organisers of the event as required by them to carry out this activity. I recognise that the treatment of the data may be using tools designed to guarantee their security and privacy of the data and that they may be manipulated using tools to memorize, manage and transmit the data . Furthermore, I declare both for myself and the other athletes named that we have read and will abide by the rules of the event; that they are fit and physically prepared; that they are willingly inscribed in the race and that they assume all the relevant risks which may arise during the participation of a cycling event. Consequently, I free the organising Association from any type of responsibility, foreseen or unforeseen, deriving from the participation in this event. I authorise the publication of any and all references to the event in newspapers, magazines, books, TV recordings and transmissions and presentations on web sites.
Date of entrance _ _ _ _ _ _ _ _ _ Signed _ _ _ _ _ _ _ _ _ |