ENTRY FORM

BikeMart SuperMoto Race. Meremere Sun 6th November 2005

in association with the Pukekohe MCC. Entry Fee (includes 2 passes) $45 or $65 late entry.Extra classes $30

For your entry you get entry in a Grade and a Bike class. Time permitting 6 races.

(Fill out (type) on screen then print off and send in)

Name

Address 1

Address 2

Town/City

Phone (day)

Email Address

Bike: Make Model cc

Preferred Race No:

Using std wheels (tick 1) No Yes

Payment: (tick 1) cheque enclosed Mastercard Visa

Card Number

Card No: Exp date

Name on card:

Please tick if you DO NOT wish to be informed of upcoming Supermoto events

Entries close on 8 of April. (accepted on day + $20)

Cheques payable to: Pukekohe MCC

Send to: Bikemart Supermoto, PO Box 803, Pukekohe.

If paying by credit card you may fax to 09-416 5308. N.B. Do not email credit card details.