Registration Rally - 08 September 2019
Drive for a good cause!
Email address *
The supported projects
In Wallonia : Les Petites Maisons - Housing for young victims of educational neglect, physical or moral abuse.
In Brussels : Les Vraies Richesses - Daycare centre for people with mental disabilities.
In Flanders : Crea Thera - An organization that offers creative activities to traumatized people.
Price
The price for 1 car with two persons is 220 € (VAT included).

You will receive an invoice mentioning all payment details.

Registration will be effective upon receipt of payment.

Driver
Name and Surname
Your answer
Address
Your answer
ZIP Code
Your answer
City
Your answer
Phone number
Your answer
E-mail
Your answer
Co-Driver
Name and Surname
Your answer
Address
Your answer
ZIP Code
Your answer
City
Your answer
Phone number
Your answer
E-mail
Your answer
Your car
Brand
Your answer
Type
Your answer
Year
Your answer
Do you want to rent a car?
We can suggest two addresses

1) The Classic Club
Chemin du Moulin 4A
1640 Rhode-Saint-Genèse
http://www.theclassicclub.com/fr/club/accueil.htm

2) Le Moulin du Mouflu
Quesnoit 28
7890 Wodecq
http://www.mouflu.be/fr/telecharger.php

Invoice
Name and surname
Your answer
Company
Your answer
VAT number
Your answer
Invoicing address
Your answer
Reference on invoice/ PO:
Your answer
Comments?
Do you have questions/ comments?
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service