Please complete the following form to sign up for membership of the Eastern Veterans Cycling Club:

When done, click the 'Create Printable Form' button to create a printable version (Licence Application Form)

Note: DO NOT PRINT THIS PAGE - PRINT AND SEND THE LICENCE APPLICATION FORM GENERATED AFTER CLICKING THE 'Create Printable Form' BUTTON AT THE BOTTOM OF THE PAGE.

Print and send the Licence Application Form to:

Mr John Macleod

21 Toppings Rd

Wonga Park Vic 3115

Note: This form must be completed in full or a licence will not be issued. 2010 fee is $140.00

Given name :
Family name:

Date of Birth (dd / mm / yyyy) :
	Note: Riders 80 years and over must have doctor's certificate and a club letter stating fitness to compete in veteran cycling events.
Sex:

Address:	(No. & Street)
	(Suburb)
	(State)
	(PostCode)

Phone:	() (Home, incl area code)
	(Mobile)

Emergency Contact:	(Not yourself)
Emergency Phone:

e-mail	(Optional)