Automaker |
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Model |
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Country of registration |
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Year of Construction |
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Number plate |
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Power KW |
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Displacement cc. |
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The undersigned declares that he or she has free use of the motor car under subscription and that he or she has filled out the technical file in conformity with the data appearing on the registration document of the car itself. |
Name |
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Surname |
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Date of birth (dd/mm/yyyy) |
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Nationality |
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Address |
Zip code
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City |
Province
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Nation |
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Fixed phone |
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Mobile phone |
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Fax |
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E-mail |
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Note |
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No membership fee will be paid for the year 2009.
It is possible for he data appearing on this form in reference to identified or identifiable persons to be controlled. The controller is the President of the OVER500CLUB, with offices in in 55049 Viareggio(Italia), via A.Saffi 3.
It is the practice of the OVER500CLUB, never to circulate the information contained here, unless the prior consent of those concerned has been given. The privacy policy of the club can be read at the address: www.over500club.org/english/policy_gb.html
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The Club cannot consider applications which have not been filled out in all their parts. |
