2005 Registration Form

Florida Freewheelers Orlando
2005 Brevet Series - Registration Form

	Date/Time	Distance	Time Limit	Cost	Amount
_____	January 8 7 AM	200 km 125 mi	13:30	$20 NonMembers $15 FFWMember	________

_____	February 5 6 AM	300 km 188 mi	20:00	$25 NonMembes $20 FFWMember	________

_____	March 5 4 AM	400 km 250 mi	27:00	$30 NonMembers $25 FFWMember	________

_____	April 2 4 AM	600 km 375 mi	40:00	$40 NonMembers $35 FFWMember	________

_____	All 4 events			$105 NonMembers $80 FFWMember	________

______ $10 late fee does apply for registration within less than 24 hours prior to the start.

Florida Freewheeler Orlando Club members receive a $5 discount per event. The annual FFW membership fee is $25 single or couple.

______ I want to join the Florida Freewheelers Orlando Club
(click here for an membership application form, fill it out and return it with the ride registration form and a separate check payable to: Florida Freewheelers, Inc. in the amount of $25.00).

Amount enclosed for events _________. Make checks payable to Michael E. Grussemeyer.

Complete and send to: Michael E. Grussemeyer, RBA, 5363 Del Monte Court, Cape Coral, FL 33904

Additional Information: http://www.bike4one.com/brevets/ -

Name: ______________________________________________________________________________

Address: ____________________________________________________________________________

City: ____________________________________ State: _______ ZIP: ___________________________

Phone: __________________________________ Cell Phone: _________________________________

E-mail: ______________________________________________________________________________

Emergency Contact:________________________ Phone: _____________________________________

RUSA Member Number _____________________ Club / ACP Code: ____________________________

Signature: ____________________________________________ Date:___________________________