Rider Information
Passenger Information
Family Name :
Family Name :
First Name :
First Name :
E-mail :
Gender :
Gender :
T-shirt :
Street :
Comments :
Postal Code :
City / Town :
Payment details:
50 € per person on the following account:
Account name: Delsinne Fabrice
Banque: BNP Paribas Fortis
IBAN: BE49001801626971
BIC: GEBABEBB
Reference: 666 miles 2023, your last name, first name "IMPORTANT !!! Do not forget !!!
Payments exclusively in Euros
Bank charges to be borne by the principal!
50 € per person on the following account:
Account name: Delsinne Fabrice
Banque: BNP Paribas Fortis
IBAN: BE49001801626971
BIC: GEBABEBB
Reference: 666 miles 2023, your last name, first name "IMPORTANT !!! Do not forget !!!
Payments exclusively in Euros
Bank charges to be borne by the principal!
Country :
Clubname :
Type of bike :
T-shirt :