Coastal Classic Online Entry Form 2011

Compulsory Fields *

Name*                             

Surname*                        

Address *                        

City*                               

Phone Number                  

Email *                                required for entry conformation

Class                        Mtb Junior Male 50km Run Vet Male 21km Run Vet Female 21km Run Open Male 12km Run Open Female 12km Run Junior Female 12km Run Vet Male 12km Run Vet Female 12km Run Masters Male 12km Run Masters Female 12km Walk Rec Male 12km Walk Rec Female 12km Run Open Male 21km Run Open Female 21km Mtb Junior Female 50km Mtb Open Male 50km Mtb Open Female 50km Mtb Vet Male 50km Mtb Vet Female 50km Mtb Masters Male 50km Mtb Masters Female 50km Mtb Recreational Male 50km Mtb Recreational Female 50km Mtb Experience Male 15km Run Junior Male 12km Mtb Experience Female 15km    Please select one

Payment Option*               Online Banking Cheque Payment         Bank Account Number    03 0905 0281740 00  Westpac

                        Use your Name/Surname in the Online identifier field

                                    Fees MTB

                                     15km course $10 per person,   50km course $30 per person,  

                                    Fees Run / Walk

                                    Run $15, Walk $10

Amount Deposited*            $10 $15 $30      

                                    Post Cheque to:  TM Events Group PO Box 7177, Mornington, DUNEDIN   

I am willing to accept material from the organisers and sponsors    Yes No

                                     Thank You