MID WALES @Abbeycwmhir 19th May 2019

Rider Name *

First

Last

Passenger Name (if applicable)

First

Last

For sidecar passengers only

Email *

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Date of Birth *//

Riding Number *

AMCA or Welsh Championship Riding Number

Classes *

Please select the classes you wish to race in

AMCA License Number *

AMCA Classic or Modern License Number; enter 0 if no license held and day license required.

AMCA Club

Machine #1 Make, Model *

Make and model of machine

Machine #1 Capacity (in cc) *

In cc numbers only

Machine #1 Year *

Year of manufacture

Machine #2 Make, Model

Make and model of machine 2 (if you have one)

Machine #2 Capacity (in cc)

In cc numbers only

Machine #2 Year

Year of manufacture

Choose your entry type *

Select the items you need; if you don't have an AMCA license you need to select a day licence. Licenses will be checked at the event.

Date / Time

Date

Time