2016 age group & u19 omnium national championship · 2016 age group & u19 omnium national...
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2016 Age Group & U19 Omnium National Championship
ENTRY FORM SIT Zero Fees Velodrome|Invercargill | 9th - 13th March 2016 The entry fee must accompany the entry form to confirm your entries and must be submitted along with full payment
Entries Close 5:00pm on 19th February 2016. Email entry forms to: [email protected]
IMPORTANT PLEASE READ
1. Please also read ‘Event Information and Criteria ’ document for more details 2. Please ensure you indicate pool riders by putting the letter 'P' in the Pool column.
3. Enter a number 1 in each event your riders are entering and ensure you add the $ amount to the Amount column and total each event.
4. Ensure you check your totals and make the appropriate payment. Any adjustments required will be notified. 5. Riders should be seeded in all events (i.e. 1, 2, 3, etc) and Centre Champions must also be noted with a ‘C’ on
the entry form.
CENTRE DETAILS (please enter all information below)
Centre Name:
Centre Secretary/Contact Person:
Contact Phone Number(s): Contact Email Address:
Team Information: Accommodation
Arrival date
Departure Date
Team Size
TEAM OFFICIALS (please enter all information below)
See criteria below Name
Phone No.
Cycling New Zealand Licence No.
Team Manager: NZ Assistant Team Manager: NZ Coaches: NZ Handlers (one per 5 riders): NZ Handlers: NZ Handlers: NZ Handlers: NZ
Please note there is a restriction on the number of officials permitted entry into the venue.
Each team will be permitted entry/accreditation to the pit for x 1 Manager, x 1 Assist Manager x 1 Coach and x 1 handler per five riders.
TEAM ENTRIES
U17 Girls - 3000m Team Pursuit
Name CNZ Licence No. Pool Qty Fee Amount
NZ $25.00
NZ $25.00
NZ $25.00
NZ $25.00
NZ $25.00
Entry Fee Total:
U17 Boys - 3000m Team Pursuit
Name CNZ Licence No. Pool Qty Fee Amount
NZ $25.00
NZ $25.00
NZ $25.00
NZ $25.00
NZ $25.00
Entry Fee Total:
Masters Women (Cat 1 & 2) - 500m Team Sprint
Name CNZ Licence No. Pool Qty Fee Amount
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
Entry Fee Total:
Masters Men (Cat 1, 2 & 3) - 750m Team Sprint - 120 Years
Name Cycling New Zealand Licence No. Pool Qty Fee Amount
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
Entry Fee Total:
U17 Girls - 500m Team Sprint
Name Cycling New Zealand Licence No. Pool Qty Fee Amount
NZ $25.00
NZ $25.00
NZ $25.00
NZ $25.00
NZ $25.00
Entry Fee Total:
U17 Boys - 750m Team Sprint
Name Cycling New Zealand Licence No. Pool Qty Fee Amount
NZ
$25.00
NZ $25.00
NZ $25.00
NZ $25.00
NZ $25.00
Entry Fee Total:
Enter this amount on the final page to reconcile your total amount
Sub Total
Omnium Entries
U19 Men Omnium Name Cycling New Zealand Licence No. UCI Licence No. Qty Fee Amount
NZ NZL $120.00
NZ NZL $120.00
NZ NZL $120.00
NZ NZL $120.00
NZ NZL $120.00
Entry Fee Total:
U19 Women Omnium Name Cycling New Zealand Licence No. UCI Licence No. Qty Fee Amount
NZ NZL $120.00
NZ NZL $120.00
NZ NZL $120.00
NZ NZL $120.00
NZ NZL $120.00
Entry Fee Total:
Enter this amount on the final page to reconcile your total amount Sub Total
INDIVIDUAL ENTRIES
IMPORTANT PLEASE READ 1. Masters Individual Pursuit and Time Trial are in 5 year age groups. See Separate entry boxes below.
Masters Women Cat 1 (35 - 44 Years)
Name Cycling New Zealand
Licence No. Scratch Keirin
Total No.
Events
Entry fee per Each Event
Amount
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
Entry Fee Total:
Masters Women Cat 2 (45 + years)
Name Cycling New Zealand
Licence No. Scratch Keirin
Total No.
Events
Entry fee per Each Event
Amount
NZ 0 $30.00
NZ 0 $30.00
NZ 0 $30.00
NZ 0 $30.00
NZ 0 $30.00
Entry Fee Total:
Masters Women 1 (35 - 39 Years)
Name Cycling New Zealand
Licence No. 2000m Ind
Pursuit 500m Time
Trial
Total No.
Events
Entry fee per Each Event
Amount
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
Entry Fee Total:
Masters Women 2 (40 - 44 years)
Name Cycling New Zealand
Licence No. 2000m Ind
Pursuit 500m Time
Trial
Total No.
Events
Entry fee per Each Event
Amount
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
Entry Fee Total:
Masters Women 3 (45 - 49 Years)
Name Cycling New Zealand
Licence No. 2000m Ind
Pursuit 500m Time
Trial
Total No.
Events
Entry fee per Each Event
Amount
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
Entry Fee Total:
Masters Women 4 (50 - 54 years)
Name Cycling New Zealand
Licence No. 2000m Ind
Pursuit 500m Time
Trial
Total No.
Events
Entry fee per Each Event
Amount
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
Entry Fee Total:
Masters Women 5 (55 - 59 Years)
Name Cycling New Zealand
Licence No. 2000m Ind
Pursuit 500m Time
Trial
Total No.
Events
Entry fee per Each Event
Amount
NZ $30.00
NZ $30.00
Entry Fee Total:
Masters Women 6 (60 + years)
Name Cycling New Zealand
Licence No. 2000m Ind
Pursuit 500m Time
Trial
Total No.
Events
Entry fee per Each Event
Amount
NZ $30.00
NZ $30.00
Entry Fee Total:
IMPORTANT PLEASE READ Masters Individual Pursuit and Time Trial are in 5 year age groups. See Separate entry boxes below.
Masters Men Cat 1 (35 - 44 Years)
Name Cycling New Zealand
Licence No. Scratch Points Keirin
Total No.
Events
Entry fee per Each Event
Amount
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
Entry Fee Total:
Masters Men Cat 2 (45 – 54)
Name Cycling New Zealand
Licence No. Scratch Points Keirin
Total No.
Events
Entry fee per Each Event
Amount
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
Entry Fee Total:
Masters Cat 3 (55+)
Name Cycling New Zealand
Licence No. Scratch Points Keirin
Total No.
Events
Entry fee per Each Event
Amount
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00 $0.00
NZ $30.00 $0.00
Entry Fee Total:
$0.00
Masters Men 1 (35 - 39 Years)
Name Cycling New Zealand
Licence No. 3000m Ind
Pursuit 750m Time
Trial
Total No.
Events
Entry fee per Each Event
Amount
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
Entry Fee Total:
Masters Men 2 (40 - 44 years)
Name Cycling New Zealand
Licence No. 3000m Ind
Pursuit 750m Time
Trial
Total No.
Events
Entry fee per Each Event
Amount
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
Entry Fee Total:
Masters Men 3 (45 - 49 Years)
Name Cycling New Zealand
Licence No. 3000m Ind
Pursuit 750m Time
Trial
Total No.
Events
Entry fee per Each Event
Amount
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
Entry Fee Total:
Masters Men 4 (50 - 54 years)
Name Cycling New Zealand
Licence No. 2000m Ind
Pursuit 500m Time
Trial
Total No.
Events
Entry fee per Each Event
Amount
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
Entry Fee Total:
Masters Men 5 (55 - 59 Years)
Name Cycling New Zealand
Licence No. 2000m Ind
Pursuit 500m Time
Trial
Total No.
Events
Entry fee per Each Event
Amount
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
Entry Fee Total:
Masters Men 6 (60 + years)
Name Cycling New Zealand
Licence No. 2000m Ind
Pursuit 500m Time
Trial
Total No.
Events
Entry fee per Each Event
Amount
NZ $30.00
NZ $30.00
NZ $30.00
NZ $30.00
Entry Fee Total:
Junior U17 Girls
Qualifying Times Required
Name Cycling New Zealand
Licence No. Sprint
500m Time Trial
2000 Ind Pursuit
7.5k Points
5k Scratch Total No.
Events
Entry fee per Each Event
Amount
NZ $25.00
NZ $25.00
NZ $25.00
NZ $25.00
NZ $25.00
Entry Fee Total:
Junior U17 Boys
Qualiying Times Required
Name Cycling New Zealand
Licence No. Sprint 500m Time Trial
2000 Ind Pursuit
10k Points 7.5k Scratch Total No.
Events Entry fee per Each
Event Amount
NZ $25.00
NZ $25.00
NZ $25.00
NZ $25.00
NZ $25.00
Entry Fee Total:
Junior U15 Girls
Name Cycling New Zealand
Licence No. Derby 500m Time Trial
1500 Scratch
5k Points
Total No. Events
Entry fee per Each Event
Amount
NZ $25.00
NZ $25.00
NZ $25.00
NZ $25.00
NZ $25.00
Entry Fee Total:
Junior U15 Boys
Name Cycling New Zealand
Licence No. Derby 500m Time Trial 2k Scratch 7.5k Points
Total No.
Events Entry fee per Each
Event Amount
NZ $25.00
NZ $25.00
NZ $25.00
NZ $25.00
NZ $25.00
Entry Fee Total:
Enter this amount on the final page to reconcile your total amount
Sub Total
TOTAL ENTRY FEES Sub Total Team Entries (Pool nominations $ refundable if no start) $
Sub Total U19 Omnium Entries $
Sub Total Individual Entries $
TOTAL ENTRY FEES DUE $
Date Payment made to Cycling Southland
Payment can be made electronically to:
o Cycling Southland o Westpac Bank, Invercargill o Account number: 03 1742 0014588 00 o Please insert your Centre Name as reference