RANDONNEUR 5000 
                        Medal Application Form

   Last Name   : ___________________________First Name : _____________ RUSA #: ______

   Address     : _____________________________________________________

   City        : ________________________State: ___ ZIP: _____________

   Club        : ____________________________  ACP Code: _____________

   RUSA#       : ____________________________  Birth Date: ___________

   Date of First Event: ________________ Date of Last Event: _________
_______________________________________________________________________________
|             |        |             |   Organizer or    |      Certification  |
|             |Distance|    Date     |   Name of Event   |          Number     |
-------------------------------------------------------------------------------
|  Brevets    |  200k  |             |                   |                     |
|             ------------------------------------------------------------------
|    de       |  300k  |             |                   |                     |
|             ------------------------------------------------------------------
| Randonneurs |  400K  |             |                   |                     |
|             ------------------------------------------------------------------
|  Mondiaux   |  600k  |             |                   |                     |
|             ------------------------------------------------------------------
|             | 1000k  |             |                   |                     |
|-------------------------------------------------------------------------------
|    PBP      | 1200k  |             |                   |                     |
|-------------------------------------------------------------------------------
|   Fleche    |        |             |                   |                     |
|-------------------------------------------------------------------------------
              Balance of Required Kilometers:
_______________________________________________________________________________
|  Brevets    |        |             |                   |                     |
|             ------------------------------------------------------------------
|    de       |        |             |                   |                     |
|             ------------------------------------------------------------------
| Randonneurs |        |             |                   |                     |
|             ------------------------------------------------------------------
|  Mondiaux   |        |             |                   |                     |
-------------------------------------------------------------------------------
For BRM/RM events not listed on the RUSA web site, attach copies (both sides) 
of original Brevet cards for the above events.

   Signature   : _______________________________ Date: _______________

Include medal payment of $10 to Randonneurs USA. Mail to:

                                 Mark Thomas
                                 RUSA R-5000 Award
                                 13543 160th Ave. NE
                                 Redmond, WA 98052

                   Deadline for submission is September 15
	         (PBP year special: in 2007, Oct. 21 deadline)