Transcript 18° MARATONINA DI UDINE 16 e 17 September 2017

18° MARATONINA DI UDINE
16 e 17 September 2017
fill out completely, sign and return by:
email: [email protected]
fax: +39 0432-299678
post: ASD MARATONINA UDINESE – Via Cotonificio, 96 – 33035 Torreano di Martignacco (UD)
SELF CERTIFICATE
Mr/Mrs/Ms (first name, last name)
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born (city, country)
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on (dd/mm/yyyy)
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resident at (complete address)
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declare
to be member of following sports club
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affiliated to a national athletics Federation
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recognized by IAAF,
until the (dd/mm/yyyy)
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Membership number card:
_____________________________________________________________________________________________________
I also declare , to be in good health and shape to compete in ATHLETICS events under the laws in my country of origin on sporting
competitions .
All this under my responsibility , knowing the consequences of a false statement , and without any liability on the part of the
organizers .
In date ____________________
Athlete's signature ____________________________________