WHALE RALLY 2017 PRE-ENTRY FORM - FAX TO: 086 403 5635
Please enter all fields, If you do not belong to a club just enter NONE. Thank you.
Rider Details – Pre Entry R230
· Date :______
· Name :______
· Surname :______
· Phone - Home/Work :______
· Cell No :______
· Email :______
· Club :______
Postal Address
· Address Line 1 :______
· Address Line 2 :______
· City :______
· State / Province :______
· Postal / Zip Code :______
· Country :______
· Date Of Birth :______
I will require a T-Shirt as follows:
Prices - R170 Long Sleeve & R150 Short Sleeve
o Long Sleeve Size SML
o Long Sleeve Size MED
o Long Sleeve Size LRG
o Long Sleeve Size XL
o Long Sleeve Size XXL
o Long Sleeve Size XXXL
o Short Sleeve Size SML
o Short Sleeve Size MED
o Short Sleeve Size LRG
o Short Sleeve Size XL
o Short Sleeve Size XXL
o Short Sleeve Size XXXL
Pillion Details – Pre Entry R230
· Date :______
· Name :______
· Surname :______
· Phone - Home/Work :______
· Cell No :______
· Email :______
· Club :______
Postal Address
· Address Line 1 :______
· Address Line 2 :______
· City :______
· State / Province :______
· Postal / Zip Code :______
· Country :______
· Date Of Birth :______
I will require a T-Shirt as follows:
Prices - R170 Long Sleeve & R150 Short Sleeve
o Long Sleeve Size SML
o Long Sleeve Size MED
o Long Sleeve Size LRG
o Long Sleeve Size XL
o Long Sleeve Size XXL
o Long Sleeve Size XXXL
o Short Sleeve Size SML
o Short Sleeve Size MED
o Short Sleeve Size LRG
o Short Sleeve Size XL
o Short Sleeve Size XXL
o Short Sleeve Size XXXL
· Number of persons :______
·
· Total Entry Due :______
Banking Details : NOTE - THE LAST DAY FOR PRE-ENTRY SUBMISSION IS 26TH MAY 2017
ABSA Bank (Mossel Bay 334-214)
Account Name: Ulysses Garden Route
Account Number: 9175765188
Please Use Initials and Surname as Reference
INDEMNITY I/We acknowledge that the ATKV Hartenbos & the ATKV Hartenbos Caravan Park are RIGHT OF ADMISSION RESERVED and agree to abide by the rules of the Organisers. I further agree to participate in the 2017 Whale Rally entirely at my own risk ______I/We Accept