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Bulletin information Plastimo Lorient Mini 6.50

Nom de course : Nom officiel :
Numéro : Série c Proto c
Je possède un moteur : Oui c Non c
Port d'attache :
Si vous n'êtes pas au port de Lorient La Base, merci d'indiquer votre date d'arrivée à Lorient :
Dimanche 7 avril c Lundi 8 avril c Mardi 9 avril c
Nom : Nom :
Prénom : Prénom :
Adresse : Adresse :
Code postal : Code postal :
Ville : Ville :
Pays : Pays :
Date de naissance : Date de naissance :
Nationalité : Nationalité :
Email : Email :
Mobile : Mobile :
Licence FFV n° : Licence FFV n° :
Club : Club :
Taille tee-shirt : Taille tee-shirt :
Compte twitter : Compte twitter :
Compte Facebook : Compte Facebook :
Nom :
Adresse :
Code postal - Ville - Pays :
Email :
Nom et Prénom :
Lien de parenté :
Adresse :
Code postal et ville :
Pays : Email :
Mobile : Fixe :
Titulaire :
4Photo du skipper format JPG / 500 Ko N° compte :
4Photo du co-skipper format JPG / 500 Ko IBAN :
4Photo du bateau JPG / 500 Ko BIC :
Je paie 220 € TTC
CONTACT EN CAS D'URGENCE
Bulletin d’inscription - 2019
PLASTIMO LORIENT MINI 6.50
Lorient Grand Large - 6 bis rue François Toullec - 56100 Lorient - skipper@lorientgrandlarge.org - 02 97 32 80 05
BATEAU
SKIPPER CO-SKIPPER
Course en double de 250 milles - 12, 13 & 14 avril 2019
RIBPIECES A JOINDRE A L'INSCRIPTION
ADRESSE DE FACTURATION

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Bulletin d inscription

1. Nom de course : Nom officiel : Numéro : Série c Proto c Je possède un moteur : Oui c Non c Port d'attache : Si vous n'êtes pas au port de Lorient La Base, merci d'indiquer votre date d'arrivée à Lorient : Dimanche 7 avril c Lundi 8 avril c Mardi 9 avril c Nom : Nom : Prénom : Prénom : Adresse : Adresse : Code postal : Code postal : Ville : Ville : Pays : Pays : Date de naissance : Date de naissance : Nationalité : Nationalité : Email : Email : Mobile : Mobile : Licence FFV n° : Licence FFV n° : Club : Club : Taille tee-shirt : Taille tee-shirt : Compte twitter : Compte twitter : Compte Facebook : Compte Facebook : Nom : Adresse : Code postal - Ville - Pays : Email : Nom et Prénom : Lien de parenté : Adresse : Code postal et ville : Pays : Email : Mobile : Fixe : Titulaire : 4Photo du skipper format JPG / 500 Ko N° compte : 4Photo du co-skipper format JPG / 500 Ko IBAN : 4Photo du bateau JPG / 500 Ko BIC : Je paie 220 € TTC CONTACT EN CAS D'URGENCE Bulletin d’inscription - 2019 PLASTIMO LORIENT MINI 6.50 Lorient Grand Large - 6 bis rue François Toullec - 56100 Lorient - skipper@lorientgrandlarge.org - 02 97 32 80 05 BATEAU SKIPPER CO-SKIPPER Course en double de 250 milles - 12, 13 & 14 avril 2019 RIBPIECES A JOINDRE A L'INSCRIPTION ADRESSE DE FACTURATION