BRIENNE CYCLO SPORT
                      BRIENNE CYCLO SPORT
 

 

                                Bulletin d'engagement

 

 

 

 

Randonnée

 

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Nom: ..............................................  Prénom : .................................

 

 

Né(e) le :......../............../.............

 

 

Adresse: rue...................................................        N°...................

 

              

                 Ville:.....................................................code postal............

 

 

Club:

 

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Ligue :................................................ n° licence FFCT......................

 

 

                                                                        

 

                                                                          Signature

 

 

 

 

                              

 

                               BRIENNE CYCLO SPORT

                               Mr HURNI Georges

                               15, Rue d'Arcis

                               10500 BRIENNE LE CHATEAU