Irish Veteran Cyclists Association Limited MEMBERSHIP APPLICATION FORM 2004 / 2005 I, the undersigned, wish to (re)apply for membership of the Irish Veteran Cyclist's Association Ltd.  In the event of the company being wound up and unable to pay its debts, I agree to contribute the sum of Euro 1.27 to the funds of the Company if and when required to do so.

BASIC MEMBERSHIP FEE 30 EURO [   ] PERSONAL ACCIDENT INSURANCE 55 EURO [   ] RACING LICENCE 80 EURO [   ] ALL OF THE ABOVE 165 EURO [   ] ARE YOU ELIGIBLE FOR FREE MEMBERSHIP? (see Note) [   ] Note Members over 66 of age with 10 years consecutive membership of the IVCA are now entitled to free membership and racing fees.  If required, they must pay for Personal Accident insurance (which is compulsory in order to race).  If you qualify for free membership and/or racing fees, you must still complete and return this form, ticking the required boxes above.

PLEASE USE BLOCK CAPITALS  Surname .......................................................... First Name ................................................. Address.................................................................................................................................. ............................................................................................................................................... ............................................................................................................................................... Date of Birth: ........................................ Club (if any):........................................................  Phone Nos:  Home: ......................... Work: ................................Mobile:........................... E-mail address: ........................................Fax: .................................................................... Signature: ............................................................. Date: ..................................................... Amount enclosed:    EURO .................................................... (Insurance cover commences when membership fee, inclusive of premium, is paid)

Completed forms should be sent, together with appropriate fee, to:- Paul Deans, 2 Green Lawns, Skerries, Co. Dublin. Cheques/Postal Orders should be made out to the  Irish Veteran Cyclists Association. Please do not send cash in the post. All members taking out a racing licence will be required to assist as marshal at events promoted by the Company. A member failing to honour this requirement will not be permitted to take part in any such events until he/she fulfils his/her duties as a marshal.