CLUB CKSH - SH Karting

CLUB CKSH
2013 SEASON
INSCRIPTION FORM
Club member will receive:
• A minimum of 6 communiques to keep you informed of current rules, news, championships, results etc.
• Specials sheets about current savings and promotions at SH Karting
Registration fees for 2013 $51.74 tax in Method of payment (√) :
Check
Cash
($25.87 tax in for the 2nd member of the same family)
Send your form with your payment directly to the CKSH at the following address:
SH Karting Inc.
N.B. Once payment has been received,
2456 4e Rang-Sud
CKSH will issue your official membership
St-Charles sur Richelieu (Quebec) J0H 2G0
card, valid until 31/12/2013.
You can also bring your form directly to SH Karting.
MEMBER IDENTIFICATION
N.B. Your personal information will remain strictly confidential.
We are however obligated to forward your details to the Fédération de sport automobile du Québec.
E-mail:
First name:
Birth date:
Last name:
Age:
Address:
No.
Tel.: (
)
Street
Apt.
(
Home
)
day / month /year
City
Weight:
Prov.
Postal code
Previous karting experience:
Office
Fax:
KART IDENTIFICATION
Chassis:
Engine:
Manufacturer
Manufacturer
Signature:
Model
Model
Year
Competition # :
(if already registered with the KQ)
Competition class(es) :
Cadet
Mini Max
Honda JR
RotaxMax JR
Year
Parent or tutor if the driver is under 18 years of age
Honda
RotaxMax
Masters
DD2
DD2 Masters
Other: ___________________
Date:
- Reserved to the administration Paiement (√):
comptant ___ chèque ___
No. de membre:
Entrée des données:
Pc(√): ___
Code client: A__ / B__ / C___
Date d'émission:
Carte émise par:
Carte: postée
donnée