Poison Rally 2013 Entry form

Poison Rally

6-8 December 2013 Kroonpark Holiday Resort, Kroonstad

Pre-paid entries – First 1000 entries only! Closing date: 06 October 2013

 

Name :___________________________________(Rider)_______________________(Club)

 

           :___________________________________(Pillion)______________________(Club)

 

Cell     :____________________________Email:___________________________________

   

Entrance Fee            : R250-00 X:________ = R__________ Includes: Metal, Cloth badge and

                                                                                                          a 200ml Poison Potion

T-Shirts                      : R70-00   X:________ = R__________ Size(XXXL – S) :___________

 

Woman vest             : R100-00 X:________ = R__________ Size(XL – S)      :___________

 

Caps                           : R60-00   X :_______ = R__________                                       

 

5-Year Badge           : R20-00   X :_______ = R__________   

                                                                                                                                               

10-Year Badge         : R20-00   X :_______ = R__________   

 

15-Year Badge         : R20-00   X :_______ = R__________    TOTAL:          

 

Poison Rally Belt Buckle    FREE to First 1000 pre-paid entries

                                                Closing date: 06 October 2013                       (PRE-PAIDS ONLY)

 

I hereby agree that I am attending the POISON RALLY 2013 at my own risk and indemnify the organisers and their agents against any damages sustained by myself as a person or belongings. I agree to behave according to the rules and instructions of the organisers and their agents. I understand the above and the instructions and the information in the entry pamphlet. I agree not to take any fire arms into the rally site and hand in all the fire arms at the gate for safe keeping.

 

Deposits        POISON RALLY                              

                        FNB – Clearwater Mall               

                        A/C No. 62345390489                                                                         

                        Branch code: 250655

                        Ref.No. “YOUR SURNAME OR YOUR CLUB NAME”

 

E-mail your deposit slip & Entry Form to Admin@PoisonRally.co.za

 In order for us to confirm your entry

Do not e-mail after the closing date – enter & pay at the gate.

 

Pre-paid entries will only be valid if you have a confirmation number.

 

Chalets are already fully booked.

 

Signature: ____________________(Rider)       Signature: ______________________(Pillion)

 

By submitting this form, I/we accept and agree with all of the above