2012 Route 72 Rally Pre-Registration - Only $25

Date to be confirmed.

NO gang patches, NO gang colours, NO gang insignia

NO glass on site

Right of admission refused (RAOR)

Rider Name *


First Name	Last Name

Pillion Name

Email Address

Address *

Phone *

Mobile

($25 per person) - I will pay by *

Cheque

Internet Bank Transfer

Cheque Number (If paying by cheque)

Bike Rego Plate Number *

Bike Make and Model

Number of T-Shirts Wanted ($25 each)

T-Shirt Sizes

I have read and agree to the terms and conditions.

Comments

* Indicates required fields

Please remember to pay by one of the two following options:

By Cheque:

By Internet Banking: