SporTriple

May 6th, 2012

Fill out entry form, print and send by mail

Chambly residents only
Course 1 km Familial	individual	Free (without chip)

Last Name:

First Name:

Address:

City:

Province :

Postal Code:

Country :

Phone:

( ) - -

Email:

Birthday :

Year Month Day

Age on december 31st :

years

Sex :

Man
Woman

Send by mail or deposit at: M. Serge Poulin, 56, rue Martel, Chambly, Quebec, J3L 1V3
NO POSTDATED CHECKS.