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ENTRY FORM
ACP Qualifying Brevet Series
(Please print clearly)
NAME: ________________________________________________________________
ADDRESS: ______________________________________________________________
CITY: ___________________________ STATE: ____________ ZIP: ______________
PHONE: (H) _______________ (W) ________________ (C) _____________________
E-MAIL__________________________________________________________________
RUSA NUMBER: ________ LOCAL CLUB AFFILIATION: ______________________
ENTRY FEES
EVENT/DATE PRICEAMT INCLUDED
PRICEAMT INCLUDEDMiddletown 200km (March 13)$15.00 $ _________
$15.00 $ _________Strasburg 200km (March 20) $15.00 $ _________
$15.00 $ _________Strasburg 200km (March 21) $15.00 $ _________
$15.00 $ _________Harrisonburg 300km (April 10)$15.00 $ _________
$15.00 $ _________Leesburg 400km (May 1) $20.00 $ _________
$20.00 $ _________Strasburg 400km (May 8) $20.00 $ _________
$20.00 $ _________Middletown 600km (May 29) $25.00 $ _________
$25.00 $ _________Bag Drop for Middletown 600k$20.00 $ _________
$20.00 $ _________Gappity Gap 200K (August 7) $15.00 $_________
$15.00 $_________Harrisonburg 300K (August 14) $15.00 $_________
$15.00 $_________Seneca Rocks 400K (September 11) $20.00 $_________
$20.00 $_________Buckhannon 600K (September 25) $25.00 $_________
$25.00 $_________Appalachian Double Cross (Oct 9) $35.00 $________
$35.00 $________Bag Drop for 600K and ADC $20.00 (Per Drop) $_________
$20.00 (Per Drop) $_________SPECIAL DEALS
Complete Series 200, 300, 400, 600 (Check events you wish to ride; no subsequent changes for $45.00 $ ________
Choose 8 ACP brevets for $75.00 $ _________
Bag drops not included in these package deals
Pre-Register for events subtract $5.00 (Entries must be post marked 5 days before event)
TOTAL: $__________
$__________CHECKS PAYABLE TO: ROMA
ROMAMAIL TO: ROMA, c/o Matt Settle, 67 Cullers Lane, Strasburg, VA 22657
ROMA, c/o Matt Settle, 67 Cullers Lane, Strasburg, VA 22657Pre-registrations must be postmarked 5 days before the first event.
_____________________________________________________________________________
Shenandoah 1200K - 2010 Application Form
(Please print clearly)
Name: __________________________________ Phone: (Day) ______________________________
Phone: (Day) ______________________________Address: ________________________________ Phone: (Eve) ______________________________
Phone: (Eve) ______________________________City: _____________________________ State/Prov.: _______ZIP/Postal Code: ______________
ZIP/Postal Code: ______________E-mail: ________________________________________ RUSA Member Number: _____________
Other Country Org. (e.g., Audax UK) / Member Number: _______ Country: _________________
☐ I will have a support crew.
☐ I am a UMCA John Marino Challenge participant.
☐ I am attempting to qualify for RAAM.
☐ Single bike ☐Tandem – Name of Partner: ___________________________________________
QUALIFICATION - List brevets you are using to qualify for the Shenandoah 1200. If you have ridden a higher-distance brevet to substitute for a lower distance or other agreed-upon substitute(s), note that to the left of the distance. If you are submitting payment prior to qualification, note "Pending Qualification" on the form and submit an updated form when you qualify.
Distance Date Location Elapsed Time Certificate Number
Date Location Elapsed Time Certificate Number200km __________________________________________________
__________________________________________________300km __________________________________________________
__________________________________________________400km __________________________________________________
__________________________________________________600km __________________________________________________
__________________________________________________1000km __________________________________________________
__________________________________________________1200km __________________________________________________
__________________________________________________Registration Deadline: June 1, 2010
Cancellations: If postmarked by May 1-full refund minus $25
If postmarked by May 15th 50 percent
Payment: (US Dollars) Check or money order made payable to ROMA is due with this application
Entry fee: $200$ __________
$200$ __________Bag drops (2): $50 $__________
$50 $__________Jersey: $75 $__________
$75 $__________ TOTAL: $__________
$__________Mail to:
Shenandoah 1200K
c/o Matt Settle, RBA
67 Cullers Lane
Strasburg, VA 22657 US
