Entry Form

Junior Roof Permit No. 10997

Competition Number
Entrant Name
Entrant  Licence Number
Rider Name
Licence Number
Nationality
Address
Telephone Number
Fax Number
E-mail Address
Club
Passport Number
ID Number
Emergency Contact
Motorcycle Make
Motorcycle Model
Capacity
Class	SELECT CLASS Bikes 65cc Junior Bikes 85cc Junior Bikes Open Bikes Seniors Quads Open Quads Junior Stock Quads Junior Modified Quads Junior Open Must Select
I/ We have read and understood GCR's 93, 94, 121 and 122 of the MSA Handbook and signify to abide by these rules by submitting this entry form.	AGREEMENT I AGREE Must select I Agree
I hereby agree to be attended by doctors/paramedics if I am injured and wish to be transported to the type of hospital indicated.	Medical Option I AGREE PRIVATE HOSPITAL I AGREE STATE HOSPITAL MED AGREE
Please note that if you have indicated that you have indicated that you wish to be treated at a private facility it is essential that you complete the following section and provide proof of medical aid /medical insurance to guarantee your admission to a private facility failing which you will be transported to the nearest medical facility.
MEDICAL INFORMATION
Personal Doctor
Doctor Phone Number
Current Medication
Allergies
Blood Group
Have you sustained a recent injury if so specify
Medical Aid
Medical Aid Number
Principal member
BANK DETAILS:     First National  Bank Maseru        Branch Code 280061 ACCOUNT NUMBER:62135494475  FAX NUMBER 082-131-560-9484

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