RANDONNEURS USA

                        1000k/2000k/3000k/4000k/5000k Medal Application

         Name        : ________________________________________RUSA#________

         Address     : _____________________________________________________

         City        : ____________________________ State: ___ ZIP: ________

         Phone       : ____________________  FAX: __________________________

         E-mail      : ___________________________________Gender (M/F):_____



         Medal:  ___ 1000k  ___ 2000K  ___ 3000k ___ 4000k ___ 5000k

         ____________________________________________________________________
         |  Date     |      Location        | Certification #  |  Distance  |
         |------------------------------------------------------------------|
         |           |                      |                  |            |
         |------------------------------------------------------------------|
         |           |                      |                  |            |
         |------------------------------------------------------------------|
         |           |                      |                  |            |
         |------------------------------------------------------------------|
         |           |                      |                  |            |
         |------------------------------------------------------------------|
         |           |                      |                  |            |
         |------------------------------------------------------------------|
         |           |                      |                  |            |
         |------------------------------------------------------------------|
         |           |                      |                  |            |
         |------------------------------------------------------------------|
         |           |                      |                  |            |
         |------------------------------------------------------------------|





    Certification numbers may be found by checking Brevet Results on the RUSA website.
    Use another copy of this sheet if needed for additional events.
    Use 360k as the distance for Fleches and Arrows and 180k as the distance for Darts.




        Signature   : _______________________________ Date: _______________


     Send completed form with a $7 check payable to Randonneurs USA by January 15 to:


                                    RUSA Awards
                                    c/o Cary Way
                                  507 Irongate Blvd.
                              Murfreesboro, TN 37129-6605