Entry form ONK Quad 2015 - Foreign Riders

OPEN CHAMPIONSHIP MOTOCROSS QUAD - 2015 - HOLLAND
Mark the races you want to enter for:
01-03 Lochem
08-03 Oss
25-05 Oldebroek
31-05 Halle
21-06 Valkenswaard
27-09 Lierop
04-10 Harfsen
INSCHRIJFFORMULIER - ENTRY FORM
NAME AND CHRISTIAN NAME:
FULL ADDRESS:
E-MAILADDRESS (!!):
Favorite startnumber:
DATE OF BIRTH:
NATIONALITY:
NAT. FEDERATION:
Licence FMN/FIM No:
Quad klasse / Class Quad
(tot/till 500cc 2&4-takt/stroke)
Merk/Machine:
Cil. inhoud/Capacity: ..........………...... ccm
□ 2-takt/stroke/temps
□ 4-takt/stroke/temps
We hereby certify that the rider is holder of the appropriate FIM license, is insured for personal accidents according to the
relevant FIM provisions and are authorised to start at above mentioned meeting.
According to Article 110.2 of the FIM Sporting Code, when granting a start permission or by issuing an FIM/UEM riders license, the
FMN is certifying that the rider is insured for personal accidents covering death, permanent disability, medical treatment and
repatriation in conformity with the FIM Regulations and Annuaire.
Date:
STAMP OF THE NAT. FEDERATION
Driver’s signature::
……………………………………………………………………………………………….
Entry-forms must be sent to:
KNMV - Postbus 650 - 6800 AR ARNHEM (NL)
fax: +31- (0)26 35 28 522 / e-mail: [email protected]

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