Please Use BLOCK LETTERS

ASA REGISTRATION NUMBER

 

 

 

 

 

 

  (See competition condition 3)

Full Name:

Date of Birth:

 

Club:

Age on 27th March 2010

 

Address:

Male/Female

 

 

Tel No:

 

 

Post Code

 

 

TIMES TO BE ACHIEVED AFTER 30th JUNE 2009

 

Entry will be based on Consideration Times and may be limited at the discretion of the promoter.

 

 

 

EVENT

TIME

 

OCCASION AND VENUE

DATE

 

 

 Long Course

Short Course

 

 

1

1500m Freestyle

 

 

 

 

2

800m Freestyle

 

 

 

 

 

 

 

 

 

I hereby declare that the above particulars are correct and that I will abide by the conditions laid down by the Lincolnshire County ASA for this competition.

 

 Signature of Competitor_______________________________________________Date_______________

 

 

Certified Correct_________________________________________________Club Secretary

 

 

  

Send the completed form, together with the entry fee of £4.00 per event to the address below.  Cheques payable to  Lincolnshire County ASA.                    

 

Sheila Smith, 48 Rudgard Avenue, Cherry Willingham, Lincoln, LN3 4JG.

 

CLOSING DATE FOR ENTRIES 10.00pm SATURDAY 19th DECEMBER 2009

LATE OR INCORRECT OR INCOMPLETE ENTRIES WILL NOT BE ACCEPTED.