(5.08.2002)

APPENDIX “Application form”

Class _____________________Team/sequence Nr __________________________________(filled by organisers)

Team name

Team members take personal responsibility for their own health condition to participate in races and personal health insurance. As well as personally undertakes not to overrule the Statement (Rules) of the adventure races “VX Rudens 2002” (VX Autumn 2002).

1. First member (captain); Name/Surname
Address Phone :
E-mail :
Nationality:
Personal ID number: Sex/gender: M F
Life insurance (if any) Signature ________
Company/level

2. Second member; Name/Surname
Address Phone :
E-mail :
Nationality:
Personal ID number: Sex/gender: M F
Life insurance (if any) Signature ________
Company/level

3. Third member; Name/Surname
Address Phone :
E-mail :
Nationality:
Personal ID number: Sex/gender: M F
Life insurance (if any) Signature ________
Company/level

4. Fourth member; Name/Surname
Address Phone :
E-mail :
Nationality:
Personal ID number: Sex/gender: M F
Life insurance (if any) Signature ________
Company/level

Team has paid "VX Rudens 2002" participation fee LVL/EUR.

Payment received by Signature

Name, surname

Date: 2002.

P.S. Pls. make your own copy of this “Application form” if you wish to keep this record