Licenza Bike Card | Asi Torino

Licenza Bike Card

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Nome

Nome

Cognome

Società di Appartenenza

Indirizzo

Indirizzo (linea 1)

seconda riga per indirizzo

Località

Stato / Provincia / Regione

Codice postale

Nazione

Sesso

M
F

Località di Nascita

Data di nascita

Email

Codice Fiscale

scrivere in maiuscolo, senza spazi fra un carattere e l'altro

Telefono

Tipologia Assicurativa

C
C1

Numero Tessera

visibile nella tessera in basso a destra

Scadenza visita medica

Categoria

MASTER

Dichiaro che il certificato comprovante la visita medica sportiva e l'assenso alla pratica del ciclismo per i minorenni sono custoditi presso gli archivi della società di appartenenza

SI

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