02.07 - GRANFONDO MARMOTTE 1 kit Etixx 01

Grand Trophée reference : ..........................................................................................
Last name : ...................................................................................................................
First name : ..................................................................................................................
Date of Birth : ..............................................................................................................
Gender :
TOP CLUB FRANCE
BP 24025
69615 VILLEURBANNE Cedex
FRANCE
Tél. +33 (0) 820 086 332
Fax +33 (0) 820 064 416
[email protected]
M
F
Adress : ..........................................................................................................................
.........................................................................................................................................
Zip Code : ............................ City : ...............................................................................
Country : .............................................................................................................
Phone : ........................................ Email : ...........................................................
LICENCE OR MEDICAL CERTIFICATE COMPULSORY :
GF Marmotte Alpes
(kit Etixx included)
95 € + deposit
2 jours Rando Marmotte
(kit Etixx included)
65 € + deposit
Trophée de l’Oisans - 4 races
with GF Marmotte (1 kit Etixx)
161 € + deposit
Grand Trophée + GF Marmotte
14 races (2 kit Etixx inclus)
450 € + deposit
DAY - RACE
Under 18s are allowed on rando and grimpees only
Enclose a parental consent
No licensed and licensed FFCT
Enclose a medical certificate of capacity in the practice of the cycling in
competition, dated of less than one year.
License :
N° License : ...................................................................................................................
GRANFONDO
02.07 - GRANFONDO MARMOTTE
1 kit Etixx
FFC
UFOLEP
FSGT
FFTRI
Handisport
Others (foreign) - Copy of License compulsory
RANDONNÉE
SOLD OUT
01 & 02.07 - RANDO MARMOTTE
Day 1 - 98 km / Day 2 - 76 km / 1 kit Etixx
RATE + TIMING CHEAP DEPOSIT
95 + 10 €
2 Jours
65 + 10 €
TROPHÉE DE L’OISANS - 4 épreuves
Vaujany - Prix des Rousses - GranFondo
Marmotte - Grimpée de l’Alpe / 1 kit Etixx
161 + 20 €
GRAND TROPHÉE + GF MARMOTTE
14 races + 2 kit Etixx
450 + 10 €
Day-5 on-site increase charge of 5€
With priority number
INSURANCE
Individual personal injury : valid for one race. Mandatory.
It is up to each participant to provide his or her own insurance against this kind of damages.
I am FCC licensed, therefore I am insured against personal injury by FFC insurance
I already have my own personal injury insurance and specifically request to not purchase
the insurance offered by the organizer.
I agree to and am aware of the personal accident insurance policy : death , disability and medical expenses
.......................... x € 5 / race
TOTAL AMOUNT :
Race(s) + deposit(s) + insurance(s)
...................................... €
Credit Card : Expiry date …..…..... / ........…. Card Number : ................................... / ........................................ / ...................................... / ......................................
Security code (3 numbers behind the Card) : …………………………
International Bank Transfer : TOP CLUB FRANCE BRAVILL - IBAN N° FR76 1046 8025 1013 9205 0020 017 - BIC N° RALPFR2G
I hereby declare that I am in good health, I have provided a medical certificate of capacity or a copy of my license. I undertake to make myself fair play. I
read and accept the cycling rules’ terms, and specially to wear the rigid safety helmet, to respect the traffic regulations, to get a light and/or a high-visibility
vest in the tunnels and the sustainable cycling commitment. I accept risks regarding the cycling practice on a road opened to traffic and I commit to control
my speed at any times.
Date : ............ / …........ / …..........
Signature :