Tour de France Roller du 08/08/2009 AU 23/08/2009 Organized by : Ecole de Roller Skating (ERS) 10 allée de l'Escopette 77186 Noisiel name / first name Sexe Date of bith ADRESS Postcode Phone Mail Person(s) to inform

M

F

city tel.domicil: Tel :

Federation N° of Licence

tel.Mobil: Name TECHNICAL INFORMATION Club Blood group

Are you have the medical competence Yes Ride discipline to practice Speed skating Downhill with Roller Ultra Endurance How many Kms per year if wating liste payment Bank transfer Personel insurence

Nationality

no * 123-

3 best result in compétition

Accept *

Refuse * CONTRIBUTION Iban number E.R.S FR11 2004 1010 1239 1913 0P03 397 -BIC:PSSTFRPPSCE Yes no * 28,45 €

Cancel insurance 16 days One week One day

Yes

no * For 16 day 30,10 euro For one week 19 euro 990 € 545 € 40 euro Repas + 8 euros Under total Total to be paid JUST FOR ORGANISATION

N° Candidat : cheque pièce jointes

Dates de Réception : med:

licence:

charte

ass civile:

ass voyage:

I autorise ERS and mark Tour de France Roller® to use and diffuse the images and the photos realize at the time of the raid to commercial purpose advertising executive on all the suports. I sertifie to have taken knowledge of the stages and i corfirm to have the level technical and physical to carry out the raid.I duly accepts the chartre to sing wich i joint with the file of inscription.

Read and approved the participant

Date

Read and approved the E.R.S

* CROSS USELESS

Under Law No. 78-17 of 6 January 1978 relating to data, files and freedoms, you have the right to oppose (art. 26), access (art. 34 to 38) and rectify (art. 36) data concerning you. So you can require that your data be corrected, completed, clarified, updated or deleted, which is inaccurate, incomplete, ambiguous, outdated or whose collection, use, communication or storage is prohibited.