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[]
["                   TRO BRO GENTLEMAN "]
["                    Trophée sportbreizh.com"]
["                        Samedi 10 Octobre 2009"]
["                       GUIPAVAS"]
["19km600 (2 tours de 9km800) Contre la Montre"]
["Premier départ à 14h (Départ toutes les minutes)"]
[]
["BULLETIN D'ENGAGEMENT"]
["Coureur"]
["Nom",null,null,"Prénom"]
["Adresse"]
["Ville"]
["Code Postal",null,null,"Date de naissance"]
["Tel",null,null,"Mobile"]
["E.mail"]
["Sexe:  M /  F"]
["CLUB"]
["Numéro de licence:"]
["Fédération: FFC / FFCT / FSGT / UFOLEP / AUTRE (rayez les mentions inutiles)"]
["Gentleman"]
["Nom",null,null,"Prénom"]
["Adresse"]
["Ville"]
["Code Postal",null,null,"Date de naissance"]
["Tel",null,null,"Mobile"]
["E.mail"]
["Sexe:  M /  F"]
["CLUB"]
["Numéro de licence:"]
["Fédération: FFC / FFCT / FSGT / UFOLEP / AUTRE (rayez les mentions inutiles)"]
[]
["Licenciés","Photocopies licence"]
["Handisport","Photocopies licence"]
["Non Licenciés","Certificat d'absence de contre-indication à la pratique du vélo en compétition datant de moins de 3 mois."]
["ENGAGEMENTS"]
["Licenciés",null,"18 ans et +  :",10,"Minimes / Cadets : 5 €"]
["Non Licenciés",null,"18 ans et +  :",13,"Minimes / Cadets : 8 €"]
["Plus 3 € pour chaque coureur non licencié FFC ( Assurance dommages corporels)"]
["REPAS",null,"10 € /Personne"]
[]
["ENGAGEMENT: "]
["Bulletin d'engagement à mailer avant le 7 octobre à redaction@sportbreizh.com"]
["Chèque (engagement de l'équipe + repas éventuels) à poster à sportbreizh - 46 rue du port - 29460 L'Hopital-Camfrout"]

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