Insurance Form

Cycle Activity Provider Scheme Application Form

PLEASE PRINT IN BLOCK CAPITALS

Title	First name		Last name
Position Held
Mailing Address
					Post code
Tel		Fax
Email				CTC Mem no. if app.

No of providers at full rate £60		Total remittance…………….
No of providers at CTC member’s rate £50		Total remittance…………….

Describe here the kind of cycle activity you are providing and give the full name, address, email and other details of all persons to be enrolled in this scheme. Use additional copies of the form as appropriate. Please note that this scheme is for named individuals only, registrations can not be re-allocated.

Payment details

Cheque

BACS, (bank details needed);

Credit Card

Invoice

Payment by Credit Card		Invoicing Details
Please charge Mastercard/Visa account For the amount of £…………………..		Order no.
		Contact name
Card no.		Name and address for invoicing
Expiry date
Is no.	Security no.
Signature
Address at which the card is registered (if different to above)
		Tel no.
		Fax no.
		Email

Cheques made payable to the Cyclists’ Touring Club.

Return to; Greg Woodford, Cycle Training Officer, CTC, Cotterell House, 69 Meadrow, Godalming, Surrey. GU7 3HS.

For details of CTC’s insurance schemes, see attached guide. The cost is per person and the scheme is subject to CTC’s terms and conditions.

CTC will not disclose this information to any other person or organisation except in connection with the above purposes. If you do not want us to contact you about CTC membership benefits, products or services, or if you have any query about the use we make of your data, please write to the Data Controller at Cyclists’ Touring Club, Cotterell House, 69 Meadrow, Godalming, Surrey, GU7 3HS.

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