Entry Form

LESOTHO ENDURO Permit No. 10728

Competition Number
Entrant Name
Entrant  Licence Number
Rider Name
Licence Number
Nationality
Address
Telephone Number
Fax Number
E-mail Address
Club
Passport Number
ID Number
Emergency Contact
Motorcycle Make
Motorcycle Model
Capacity
Class	SELECT CLASS OPEN E1 3 Loops 200cc E2 3 Loops SENIORS 2 Loops MASTERS 1 1/3 Loops SILVER 2 Loops Novice 1 1/3 Loops Fun Rider 1 Loop 400 Plus 2 loops Must Select
I/ We have read and understood GCR's 93, 94, 121 and 122 of the MSA Handbook and signify to abide by these rules by submitting this entry form.	AGREEMENT I AGREE Must select I Agree
I hereby agree to be attended by doctors/paramedics if I am injured and wish to be transported to the type of hospital indicated.	Medical Option I AGREE PRIVATE HOSPITAL I AGREE STATE HOSPITAL MED AGREE
Please note that if you have indicated that you have indicated that you wish to be treated at a private facility it is essential that you complete the following section and provide proof of medical aid /medical insurance to guarantee your admission to a private facility failing which you will be transported to the nearest medical facility.
MEDICAL INFORMATION
Personal Doctor
Doctor Phone Number
Current Medication
Allergies
Blood Group
Have you sustained a recent injury if so specify
Medical Aid
Medical Aid Number
Principal member
BANK DETAILS:     First National  Bank Maseru        Branch Code 280061 ACCOUNT NUMBER:62135494475  FAX NUMBER 082-131-560-9484

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