2013 Bell's Beer Iceman Cometh Challenge

S A T U R D A Y ,

N O V E M B E R

2 , 2 0 1 3

Last Name __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __

Official
Entry Form
24th Annual

First Name __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __
Address __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __
Address __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __
City __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __
State/Province __ | __ | __

Zip/Postal Code __ | __ | __ | __ | __ | __

email __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __
Phone __ | __ | __ | __ | __ | __ | __ | __ | __ | __ USAC License #__ | __ | __ | __ | __ | __
Birth Date (mm/dd/yy) ___ /___ /___ Age as of 12/31/13 __ | __ Sex:

Team __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __

You must have a USA Cycling

account number in order to
register. If you do not have a USA

Past Results for Seeding __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ Year:_______

Cycling account, you may obtain

one at www.usacycling.org.

Category: (circle one)

Iceman Pro & Category 1 ...............................................................................($78.00)
Iceman Age Based Category ..........................................................................($78.00)
Iceman Tandems............................................................................................($78.00)

USA Cycling Permit 2013-715

Stoker's First Name:_____________________ Last Name:______________________

Iceman Single Speed .....................................................................................($78.00)

You must also sign your 2013

Iceman Clydesdales .......................................................................................($78.00)

Bells Beer Iceman release form

Iceman MYC Junior Categories (18 and under) ..............................................($48.00)

electronically once your entry has

Meijer Slush Cup (8 mile race) .......................................................................($48.00)

been processed. Just log-in to

your account and you will see a
notation to sign the release where
it shows that you are registered

Credit Card: Visa and MasterCard Accepted

for the 2013 Bells Iceman.

Card # __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __
Exp. Date ______ | ______ 3-Digit Security Code On Back Of Card __ | __ | __
Name On Card __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ | __
Signature ________________________________________________________

Return to:

Iceman Promotions, Inc.

P.O. Box 3127 Traverse City MI 49685-3127

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