Entry form ONK MX Sidecars 2015 - Foreign Teams

OPEN CHAMPIONSHIP MOTOCROSS SIDECAR 2015 – HOLLAND
Mark the races you want to enter for:
01-03 Lochem
08-03 Oss
31-05 Halle
21-06 Valkenswaard
27-09 Lierop
04-10 Harfsen
INSCHRIJFFORMULIER - ENTRY FORM
RIJDER/DRIVER
PASSAGIER/PASSENGER
NAAM EN VOORNAAM/
NAME AND CHRITIAN NAME:
VOLLEDIG ADRES/
FULL ADDRESS:
E-MAILADDRESS !!:
GEBOORTEDATUM /
DATE OF BIRTH
NATIONALITEIT/
NATIONALITY:
BOND / FEDERATION:
FIM LIC.NO:
Favorite start number:
MOTORMERK/MARK: ………………………………………………………………
CILINDERINH./CAPACITY: …………………. ccm
We hereby certify that the rider/passenger 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.
STEMPEL VAN DE NAT. BOND
STAMP OF THE NAT. FEDERATION
Datum/Date:
Handtekening rijder/
Driver's signature:
Handtekening passagier/
Passenger’s signature:
FMN !!
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Formulieren opsturen naar/Entry-forms must be sent to:
KNMV - Postbus 650 - 6800 AR Arnhem - Holland
fax: +31 (0)26 35 28 522 / e-mail: [email protected]
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