2005 12 Hours of Tsali Team #:

Team Entry Form (up to 4 members) (assigned by officials)

Team Name:____________________________________________________________________________________

Class (please check):

___12 Hour Solo (please circle class also) - Beginner / Sport / Expert / Female / Single Speed

____6 Hour Solo (please circle gender also) - Male / Female

___Team (please circle class also) - Beginner under 125 years / Beginner over 125 years / Sport / Expert / Co-Ed / Women

Rider 1 Age:_____ Total age of team (if a beginner class)_______

Name:_________________________________________________________________________________________

Address:_______________________________________________________________________________________

City: _____________________ State:____________________ Zip:________________________________________

Phone:_______________________________ E-mail:___________________________________________________

NORBA cross country class:_____________________ NORBA#: _________________________________________

Signature (by signing rider agrees to NORBA wavier on back side of this sheet)______________________________

Rider 2 Age:_____

Name:_________________________________________________________________________________________

Address:_______________________________________________________________________________________

City: _____________________ State:____________________ Zip:________________________________________

Phone:_______________________________ E-mail:___________________________________________________

NORBA cross country class:_____________________ NORBA#: _________________________________________

Signature (by signing rider agrees to NORBA wavier on back side of this sheet)______________________________

Rider 3 Age:_____

Name:_________________________________________________________________________________________

Address:_______________________________________________________________________________________

City: _____________________ State:____________________ Zip:________________________________________

Phone:_______________________________ E-mail:___________________________________________________

NORBA cross country class:_____________________ NORBA#: _________________________________________

Signature (by signing rider agrees to NORBA wavier on back side of this sheet)______________________________

Rider 4 Age:_____

Name:_________________________________________________________________________________________

Address:_______________________________________________________________________________________

City: _____________________ State:____________________ Zip:________________________________________

Phone:_______________________________ E-mail:___________________________________________________

NORBA cross country class:_____________________ NORBA#: _________________________________________

Signature (by signing rider agrees to NORBA wavier on back side of this sheet)______________________________

Costs:

Teams: $100 pre-entry with $25 late fee after 5/19/05

Expert: $150 pre-entry with $25 late fee after 5/19/05

12 Hour Solo: $50 pre-entry with $10 late fee after 5/19/05

6 Hour Solo: $40 pre-entry with $10 late fee after 5/19/05

Norba non membership fee $5 per rider

Note: If your team is downloading this form be sure to read the rules on the online flier and download the NORBA release form and attach to this form when mailing in.

Mail to: Gone Riding / 10915 SW 58^th Ave Road / Ocala, Fl 34476

*The 2005 12 Hours of Tsali is a GONE RIDING, Inc. Race Production.