Tout Agen court à Noël - 5 et 10 kms BULLETIN D’INSCRIPTION Samedi 3 décembre 2016 – Départ 20H00 Zone réservée à l’organisateur
Numéro de dossard : ……………………………………………..
NOM : …………………………………………… N° DE LICENCE : …………………………………………. PRENOM : ……………………………………… NOM DU CLUB : ………………………………………….. DATE DE NAISSANCE : ………………………….. NATIONALITE : ………………………………………. SEXE : Masculin Féminin CATEGORIE : MINIME CADET ESPOIR SENIOR VETERAN CHOIX DE LA COURSE : 10 KM (à partir de cadet seulement) 5 KM ADRESSE : …...…………………………………..………………………………………………………. ………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………. CODE POSTAL : …………………………. VILLE : ………………………………………………….. TELEPHONE : …………………………….. MAIL : …………………………………………………… Inscriptions obligatoirement accompagnées : - de la copie de la licence en cours de validité, oud’un certificat médical de moins d’un an, pour les 2 courses -Du chèque libellé à l’ordre de ASPTT Agen
TARIF : Inscription par courrier (tarif unique)
5 km
10km
8€
13€
A adresser par avant le jeudi 1er décembre 2016, cachet de la poste faisant foi à : ASPTT Agen Athlétisme 292 rue de Lille 47000 AGEN Possibilité d’inscription en ligne : http://www.pb-organisation.com Je reconnais avoir lu le règlement et l’accepter.
... en ligne : http://www.pb-organisation.com. Je reconnais avoir lu le règlement et l'accepter. DATE ET SIGNATURE. Page 1 of 1. bulletin inscription 2016.pdf.
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