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Van/Surname:		Naam/Name:
Mediesefonds: Medical Aid:		Mediesefonds No: Medical Aid No:
ID Nommer: ID Number:		Geslag/Sex:	MaleFemale
Posadres: Postal Address:		Poskode: Postal Code:
Telefoon No: Telephone No: Cell		(H)
E-pos Adres E-Mail Address:
Nood Tel No: Emergency Tel No:		Kontakpersoon: Contact Person:

	XS	S	M	L	XL	1XL	2XL	3XL	4XL	5XL
Fietsryhemp Grootte /Cycling Shirt Size:	XS	S	M	L	XL	XL1	XL2	XL3	XL4	XL5
Fietsrybroek Grootte /Cycling Pants Size:	XS	S	M	L	XL	XL1	XL2	XL3	XL4	XL5
Armverwarmers/Arm warmers:	XS	S	M	L	XL	XL1	XL2	XL3	XL4

I agree to all terms and conditions
Handtekening/Signature	Datum/Date

Betalings kan soos volg gemaak word/Payments can be made as follow:

• Elektroniese Bankbetaling/ Electronic Fund Transaction (EFT) – Faks bewys/Fax confirmation: 086 513 0866
  FNB Tjekrekening/ FNB Cheque Account, Branch Code/Takkode 270 324, Rek/Acc no: 624 2571 3113
• Kontantinbetaling slegs by Klubhuis op die eerste Donderdag van die maand / Cash payment at the Club House (only) on the
  first Thursday of each month 17h30 - 19h00
• NO CASH/CHEQUE PAYMENTS AT BANK/GEEN KONTANT/TJEK INBETALINGS BY BANK!!!! (Additional R20 shall be
  charged/ Addisionele R20 bybetaling sal gehef word)
• Nota: CSA lidmaatskap en Lisensie aansoeke moet self op webtuiste gedoen word / CSA Membership and License
  applications must be done by yourself on website: www.cyclingsa.com

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Please use your reference code when making payment - Ref: