Cognome e Nome_________________________________________________________________

Surname/First name

data e luogo di nascita______________________________________________________________

Date of Birth

Indirizzo: via/corso_____________________________________________n° _________________

Postal Adress

                    citta’_____________________________________________c.a.p.________________

 Telefono e fax__________________________________eventuale cellulare__________________

e.mail ______________________________________Cod. Fiscale__________________________

eventuale  numero di tessera/licenza CSAI ___________________________

Lic. international                                                                 Eventuale tessera A.S.I. n° _________________ 

Costi: tessera Scuderia Veltro Auto/moto                                                                      € 62,00

tessera Scuderia Veltro solo moto                                                                                € 50,00

tessera A.S.I.                                                                                                                 € 41,00

 Scheda vettura:

marca e tipo____________________________________________________________________

Car: make and model

cilindrata______________________colore______________________categoria_______________

Engine size                               color                                         Categori

targa N°___________________________________anno di fabbricazione____________________

Registration n°                                                                              Year manufacture

Eventuale numero di omologazione  A.S.I. / CSAI _____________________________

 in fede (signature) ______________________________