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APPLICAT ION FORM PLEASE, FILL THE APPLICAT ION FORM AND SEND IT TO THE ORGANIZAT IO N BY FAX OR BY E-MAIL ( fabrizio.fantini@tin.it ) THE FORM MUST BE SIGNED IN ORIGINAL, THE DAY OF THE RACE

Rider name ………………………..rider surname ………………. place of birth……(date of birth)…….. Address………ZIP code……City…….. Country ………..telephon/fax……… E-mail……..@…….. Member of the Sporting Association………………….. Region of the Sporting Association UISP member card No. …….issued on ……… UISP Pocket Bike License No……….. Medical examination, date of expiry …………. I intend to ride the following 2009 UISP pocket bike championships: • Absolute Pocket bike Trophy • Italy Pocket Bike Trophy • Emilia Romagna Pocket Bike Regional Championship In the following Class: Chickens/Spring/Boys/Senior A/Senior B/ Senior C/minimotard Senior Open Number Plate No. …….. Frame ……… Engine brand ………..-stroke Fully conscious of the criminal sanctions fixed by the Article 76 T.U. 445/2000, in case of false statements, forgery, use of forged documents, including data not corresponding to the truth I DECLARE: 1. that my pocket bike has the requisitions asked by UISP Motorcycle Rules 2. to wear the consistent protective clothing during each practice or race session 3. to be helped by Mr. ……… … holder of the valid UISP motorcycle member card No. ….. issued on …… 4. I will pour the tax registration in the previewed way I also declare to have taken note and approved the Rules of Motorcycle League concerning competitions: Date ………………………………………………….…rider signature …………………………..


Parent’s signature, if the rider is under age …………………………………………………….. ----------------------------------------------------------------------------------------------------------------------------------With reference to D.L. 196 of 30-06-2003 about privacy, for personal data we are collecting, the following rules apply: the information you provide will not be made available to third parties. You have the right at any time to see the personal information we have stored, to correct it or to have it deleted. Date ………………………………………………….…rider signature ………………………….. parent’s signature if the rider is under age ………………………………………… Instructions on filling the Application Form • • •

Enter the required data in dots place ASD: name of the Rider Sporting Association Class: delete the class you don’t belong to

Date, Signature: don’t sign please, the signature must to be affixed in  original the day of the race; in that occasion the full of age person will be  requested to produce a copy of the identity card 

 
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