2007 Licence Application Form

2012 DOMESTIC LICENCE APPLICATION & MEMBERSHIP FORM

BikeNZ issues Race Licences for Road and Track racing which are valid for one calendar year.

A BikeNZ Race Licence allows you to compete in most road, track and mountain bike events run by an affiliated Club or Centre, or sanctioned by BikeNZ Road & Track (BR&T), BikeNZ or Mountain Bike NZ (MTBNZ). Note: You may need a clearance from your club and in some instances, e.g. National Championships, you may also need to be a financial member of the Member Organisation holding the Championships. Ensure you check the specific event’s licence requirements.

You cannot use a BikeNZ licence to compete in BMX events. For details on licences for BMX, contact BMX NZ on

YOUR MEMBER ORGANISATION

You must select BRT as your Member Organisation. Completion of this form records your agreement to be a member of your chosen Member Organisation. This is the organisation with whom your licence is held, and you are bound by its constitution, rules and regulations. In most cases, your affiliated club will determine your Member Organisation. However there are a number of clubs that are affiliated to both BRT and MTBNZ. If you have any queries regarding this, please talk with your club.

RACE LICENCE TYPES

There arefour types of race licences available: Club (BRT only), Centre (BRT Only), National and International, and, asthe names suggest, each licence allows you to race in the different levels of competition. Please note for Junior U15 or U17 riders the ONLY licence type available are national licences.

You must be a financial member of an affiliated club to be eligible for a racing licence. See www.bikenz.org.nz for details on affiliated clubs.

You are able to upgrade throughout the year by paying the difference in fees. Contact BikeNZ for further information.

INTERNATIONAL LICENCES

Please note this is the domestic licence form. If you require an international licence please go to www.bikenz.org.nz and download the international licence form.

TECHNICAL LICENCES

A Technical Licence caters for Commissaires, Coaches, Managers, Mechanics and Soigneurs and allows licence holders to attend Club, Centre, National and International Events in an official capacity. For BRT members, technical endorsements on domestic racing licences are free. If you don’t hold a race licence, your technical licence will attract the published fee of $30.

LICENCE CATEGORIES

Your Licence Category states which category you compete in, and in most cases, is determined by your age. There are circumstances, however, which allow you to compete outside your normal category. Contact your club for further details.

Where you use your licence with another Member Organisation, your category may vary according to the category structure.

SUBMITTING THIS APPLICATION

BRT Members

Please submit this application and all relevant fees (including Club and Centre Fees) to your Club. Do not post to BikeNZ unless you are applying for either a Technical Licence, or an International Licence Upgrade. It may take up to four weeks from the time your club receives your application until you receive your physical licence.

You can also apply for a licence online, go to www.bikenz.org.nz and click the online membership button.

FOR MORE INFORMATION

Contact your club (details found on www.bikenz.org.nz) , or BikeNZ:

PH 04 5600 333 FAX 04 5600 400 EMAIL WEB www.bikenz.org.nz

PO Box 38170, Wellington Mail Centre, Lower Hutt 5045, New Zealand

New Member o / or 2011 Licence Number: ______

In applying for membership I agree to the personal information specified in this form being collected, held, disclosed and used for the purposes set out in this form. I understand that if I do not complete all of this section my application for membership may be declined.

PERSONAL DETAILS

GIVEN NAME / SURNAME
POSTAL ADDRESS Street / PHYSICAL ADDRESS
Suburb/RD / (if different from postal)
Town
Postcode
PHONE Home / ( ) / Cell
EMAIL
AFFILIATED CLUB / Trade Team
Emergency Contact Name: / Phone Number:
DATE OF BIRTH (da/mo/yr) / / / / GENDER / Male / Female
SPONSORS (25 characters max) / ______

LICENCE TYPE Please circle

CLUB
(BRT Only Over 17 yrs) / CENTRE
(BRT Only Over 17 yrs) / NATIONAL
Under 17 yrs / NATIONAL
Over 17 yrs / TECHNICAL
(circle fee) / UPGRADE
$25
/ $40 / $25 / $80 / $0 / $30 / From ______
To ______

Please note BRT Race Licences also include a Club and Centre Fee in addition to the fee listed.

LICENCE CATEGORY (Race age category)

Para-Cycling Please circle Category - C - 1 2 3 4 5 H - 1 2 3 4 B - 1 2 3 T - 1 2
Elite / International Licences Only
Under 15 / Born 1 January 1998 and after
Under 17 / Born 1 January 1996 – 31 December 1997 (15-16 yrs)
Under 19 / Born 1 January 1994 – 31 December 1995 (17-18 yrs)
Under 23 / Born 1 January 1990 – 31 December 1993 (Male only 19-22yrs)
Senior / Born 1 January 1978 – 31 December 1989 (Male) (23–34 yrs)
Born 1 January 1978 – 31 December 1993 (Female) (19-34 yrs)
Master 1 / Born 1 January 1973 – 31 December 1977 (35-39 yrs)
Master 2 / Born 1 January 1968 – 31 December 1972 (40-44 yrs)
Master 3 / Born 1 January 1963 – 31 December 1967 (45-49 yrs)
Master 4 / Born 1 January 1958 – 31 December 1962 (50-54 yrs)
Master 5 / Born 1 January 1953 – 31 December 1957 (55-59 yrs) / Please note BRT Track Race Category Variances below
Master 6 / Born 1 January 1948 – 31 December 1952 (60-64 yrs) / Cat 1 – Includes Master 1 & 2
Master 7 / Born 1 January 1943 – 31 December 1947 (65-69 yrs) / Cat 2 – Includes Master 3 – 4
Master 8 / Born before 31 December 1942 (70 yrs +) / Cat 3 – Includes Master 5 – 8

TECHNICAL See description on page 1 for details on technical licence fees applied by BRT.

o International Commissaire ($30) / o National Commissaire ($30) / o Centre Commissaire ($30) / oCoach ($30)
oManager ($30) / oMechanic ($30) / oSoigneur ($30) / o Other ______

DECLARATION

I, the person who has applied to BikeNZ and either BRT or MTBNZ (my Member Organisation) for a Licence and to become a member of my Member Organisation:

1. Declare that:

(a) I am not aware of any reason why I should not be issued with the licence requested;

(b) I have not applied for a licence for the same year to the International Cycling Union (UCI) or to any other national cycling federation;

2. Undertake to:

(a) return my licence immediately in the event of any substantial change to the circumstances existing at the time of this application;

(b) comply with the constitutions, regulations, policies, manuals, guidelines and reasonable directions of BikeNZ, my Member Organisation and the UCI ;

(d) submit to disciplinary measures taken against me by BikeNZ, my Member Organisation or the UCI and take any appeals and litigation before the authorities provided for in the Constitution or Regulations of BikeNZ, my Member Organisation or the UCI;

(e) accept the Judicial Panels established by BikeNZ and my Member Organisation , the New Zealand Sports Disputes Tribunal and the Court of Arbitration for Sport (CAS) as the only competent jurisdictions in cases provided for by the Regulations of BikeNZ, my and UCI and that, in the case of CAS, its decisions will be final and binding and not subject to further appeal;

(f) subject to paragraph (e), submit any litigation with the UCI exclusively to the tribunals at UCI headquarters.

3. Undertake to comply with the Anti-Doping Policies of BikeNZ and my Member Organisation, the UCI Anti-Doping Regulations, the clauses of the World Anti-Doping Code and its International Standards to which the UCI Anti-Doping Regulations refer, as well as the anti-doping regulations of other competent bodies as per the UCI Anti-Doping Regulations and the World Anti-Doping Code, provided that those regulations comply with the World Anti-Doping Code. I accordingly acknowledge and accept:

(a) that all urine samples taken will become the property of the UCI, which may have them analysed, especially for purposes of health protection research and information;

(b) that the results of any analysis may be made public and communicated in detail to my club or team or to my paramedical assistant or doctor;

(c) that my doctor or the doctor of my club or team may, on request from the UCI, communicate to the UCI a list of any medicines I took and treatment I underwent before any given competition;

(d) the conditions regarding blood testing and agree to undergo blood tests.

4. Warrant that the details set out in the Application for a Licence and Membership Form are true and correct. If they change I acknowledge that I am required to notify BikeNZ of the changes, in writing, as soon as possible after they occur.

5. Understand and agree that:

(a) BikeNZ and my Member Organisation may use the information collected in this form for purposes relating to my membership of BikeNZ and my Member Organisation and for communicating with me about my membership and matters affecting my Member Organisation and BikeNZ;

(b) The information will also be recorded on a BikeNZ databases;

(c) BikeNZ and my Member Organisation may disclose the information to third parties, including sponsors, stakeholders, the UCI and other organisations referred to in this form;

(d) I will have access to my personal information; and my personal information will be corrected on request.

6. Acknowledge and agree that, where I participate in an event organised by BikeNZ, a Member Organisation or a club affiliated to a Member Organisation:

(a) I am aware of the dangers of road racing and the real risk of injury and accept all risks flowing from my participation in every event;

(b) I am responsible for reading and understanding any written race instructions;

(d) Briefings, signage, and course marshals, are a service to me and other competitors but are not a guarantee of safety;

(e) Should circumstances require a change of format or categories within an event, I consent to those changes being made by the organisers;

(f) As the organisers cannot control every eventuality, I release all persons associated with every event from any claims arising out of my participation;

(g) If I am involved in an accident, I will not seek to blame or make a claim against the organisers; nor will I assist anyone else in making such a claim;

(h) In the event of an accident I consent to receiving any medical treatment the event organiser or medical or paramedical personnel think necessary;

(i) I am responsible for the roadworthiness and safety of my bicycle and the security of all other equipment and personal possessions used in connection with every event;

(j) If I have any concerns with the race organisation, I will raise them with the organisers first.

Signature ……………………………………………………. Date …………………………………………………………………

Under 18yrs, parent, guardian, caregiver to consent

I am the parent/guardian/caregiver of the applicant who is under 18 years of age. I have read and understood the application for licence and membership form and the applicant’s declaration. I have explained the effect of this form to the applicant. I understand the form and the declaration and consent to the applicant’s application for a licence and membership on the basis set out in the form and declaration.

Surname ……………………………Given name ………………………….. Signature …………………………… Date ………………………..

PAYMENT DETAILS TO BIKENZ

Licence Fee /

$ ______
TOTAL AMOUNT / $ ______