Entry Form

		Entry Form

Sunday 4th March 2012

Select your event by clicking on the above table
then fill in the competitor details below

INDIVIDUAL OR TEAM MEMBER 1: Swimmer or Individual Duathlete

First Name:	GRADE
Last Name:		14	-	19	years	50	-	59	years
Address		20	-	29	years	60	-	69	years
Town/City		30	-	39	years	70	+		years
Postcode		40	-	49	years
Phone:
Mobile:	Enter Date of Birth (dd-mm-yyyy)
Email:	Day				Month		Year
To assist the organisers, please enter your expected swimtime
100m 750m

TEAM MEMBER 2: Cycle

First Name:	GRADE
Last Name:		14	-	19	years	50	-	59	years
Address		20	-	29	years	60	-	69	years
Town/City		30	-	39	years	70	+		years
Postcode		40	-	49	years
Phone:
Mobile:	Enter Date of Birth (dd-mm-yyyy)
Email:	Day				Month		Year

TEAM MEMBER 3: Run

First Name:	GRADE
Last Name:		14	-	19	years	50	-	59	years
Address		20	-	29	years	60	-	69	years
Town/City		30	-	39	years	70	+		years
Postcode		40	-	49	years
Phone:
Mobile:	Enter Date of Birth (dd-mm-yyyy)
Email:	Day				Month		Year

NEWSLETTER & TEAM NAME

Subscribe to NCTri Newsletter YesNo Team Name

PAYMENT & METHOD

Individual

$45

Individual (Late Entry)

$70

Team

$75

Team (Late Entry)

$100

TOTAL PAYMENT

Please Indicate your method of payment
ChequeInternet Payment/Direct Credit Transfer

Enter the total amounts in the above boxes

Make cheques payable to NORTH CANTERBURY TRIATHLON.
For Direct Credit (Internet Banking Only), you can deposit your entry fee directly
to the NCTri account. ACCOUNT NUMBER: 03 0674 0103428 00
Please reference your name and phone number on the Internet transfer.

DECLARATION

I acknowledge I have read and understood the declaration and declare all information is true and correct. (Tick box to acknowledge declaration)
The declaration is available here