Entrant application:

Surname:

Name:

Male:

Female:

Birth date (gg/mm/aaaa):

Nationality:

Address:

Zip code:

Town:

Provincie:

Phone:

Telefax:

E-mail:

Club code:

Club name:

Best time (hh:mm:ss):

Fidal athletes:

Fidal senior/master:

Fidal membership number:

Other (state below):

Other group or federation:

I have the personal chip:

Personal chip code:

I will take part in the football referees championship:

I will take part in the 42Km marathon for people with disabilities:

Si, partecipo alla 42Km per il Trofeo Avis:

Numero tessera Avis: