2005 INTERNATIONAL LICENSE APPLICATION
USAC License #________________________________________
UCI Elite UCI Junior (18 years & under) UCI Master (30 years & over)
All UCI licenses expire December 31 of the year issued
RIDERS AGE 30 AND OVER WILL BE ASSIGNED A MASTERS DESIGNATION UNLESS OTHERWISE REQUESTED
You must provide a U.S. address to obtain an international license through USA Cycling. You must provide proof of citizenship, whether U.S. or otherwise, to obtain an international license. You are required to attach a photo of yourself to the backside of your international license. Do NOT send a photo with your international license application. Any position of trust as determined by USA Cycling may require a background check. Your acceptance of your license is your consent.
1. 2.
LAST NAME: DOMESTIC MAILING ADDRESS: City:
FIRST NAME:
MIDDLE INITIAL: ______
State:
_________________Zip__________________________
3. 4. 5. 6.
CITIZENSHIP:____________________________________________________________________________________________ You must provide a copy of your passport or birth certificate (and if applicable, a copy of your permanent resident alien card). DATE OF BIRTH: UCI TRADE TEAM: DOMESTIC CLUB NAME/FOREIGN CLUB NAME: PHONE: EMAIL: __________ ___________
INTERNATIONAL LICENSE FEES
US Citizen OR permanent resident alien requesting International License US Citizen OR permanent resident alien with current USCF OR NORBA license adding an International License US JUNIOR Citizen OR permanent resident alien with current USCF OR NORBA license adding an International License US Citizen OR permanent resident alien with current USCF AND NORBA license adding an International License US JUNIOR Citizen OR permanent resident alien with current USCF AND NORBA license adding an International License US Citizen OR permanent resident alien with current NCCA only license adding an International License Foreign Citizen living in the United States requesting International License Indicate 24-Hour Processing on envelope for expedite options: Add 24 Hour Priority Processing of application (application will be processed within 24 hours of receipt) 24 Hour Priority processing of application AND express mail return via overnight service. No foreign addresses. Add
$ 150.00 $ 90.00 $ 120.00 $ 60.00 $ 90.00 $ 120.00 $ 175.00 $ 20.00 $ 35.00
OPTIONAL DONATIONS: USA Cycling Development Foundation supports American athlete development programs Junior & U-23 Athlete Development - offers travel/training grants to outstanding Junior and U-23 athletes Stenner Collegiate Scholarship Fund awards outstanding collegiate cyclists for their hard work on and off the bike World Championship Team Travel - supports our junior and under-23 riders to the World Championships Trail Tune-up Grant - awards clubs that improve trails used for racing TOTAL AMOUNT ENCLOSED $ _____Check or money order made payable to USA Cycling, Inc. Card #___ ___ ___ ___/___ ___ ___ ___/___ ___ ___ ___/___ ___ ___ ___ _____VISA
$______ $______ $______ $______ $______
_____MasterCard
Expiration Date:___ ___/___ ___
Name on card:_____________________________________________________________________________________________________________ Address of card holder:________________________________________________City:________________State:_____________Zip:______________ Signature__________________________________________________________
THE FOLLOWING INFORMATION IS REQUIRED TO PROCESS YOUR LICENSE
1. 2. 3.
CURRENT RESIDENCE_________________________________________________________________________________________________ PREVIOUS ADDRESS: City: State: Zip: Country:
Have you been issued a license by the UCI or a National Federation other than USA Cycling in the last calendar year? If yes, provide the name of the issuing organization:
Yes No
4. 5.
Have you been denied a license in the last three years? If yes, what National Federation (or UCI) denied the license? Are you currently under suspension? If yes, what National Federation (or UCI) issued the suspension? Suspension Dates: From Reason for Suspension: _ ( MONTH / DAY / YEAR) to
Yes No Yes No (MONTH / DAY / YEAR)
CONTINUED ON THE NEXT PAGE
Applicant Declaration I am not aware of any reason why the requested license should not be issued. I have not requested a license from the International Cycling Union (UCI) or from any other national federation for the calendar year. I am solely responsible for the information contained in this application and for the use I shall make of the license. I shall undertake to respect and comply with the constitution and regulations of the UCI, its Continental Federations, and its National Federations. I declare having had the opportunity to read such constitution and regulations. I agree to compete in a sporting manner. I shall submit to disciplinary measures taken against me and shall take any appeals and litigation before the authorities provided for in the regulations. I accept the Court of Arbitration for Sport (CAS) as the only competent jurisdiction of appeal in the cases provided for by the Regulations and in compliance with the terms thereof. I accept that the decisions of CAS shall be final and binding and not subject to appeal. With that reservation, I shall submit any litigation with the UCI exclusively to the tribunals at UCI headquarters. I agree to submit to drug testing and to comply with and to be bound by the UCI anti-doping regulations, 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 instances as foreseen by the UCI Regulations, the World Anti-Doping Code, or the U.S. Anti-Doping Agency (USADA), provided such regulations comply with the World Anti-Doping Code. I further agree that the results of the analysis may be released to the public and communicated to my trade team, coach, or doctor in accordance with UCI and WADA regulations. I agree to allow my doctor and/or the doctor of my team, upon the request of the UCI or WADA, to release to UCI and WADA officials a list of medications or treatments administered to me before any specific competition. I agree that all urine samples in such cases taken shall become the property of the UCI and WADA, and that UCI and WADA may have them analyzed for any purpose, including, without limitation, general research and information on health protection. I accept these conditions regarding blood testing and agree to undergo all tests required of me.
Coach and Mechanic Certification Notice
Certification by USA Cycling of a coach or mechanic means only that the individual has satisfied certain minimum educational, experience and skill requirements established by USA Cycling; it does not otherwise constitute an endorsement or recommendation of the individual as a coach or mechanic. USA Cycling certified coaches and mechanics are solely responsible for their own actions or failure to act in their respective roles; USA Cycling shall have no responsibility or obligation whatsoever for such acts or failure to act. Each USA Cycling certified coach and mechanic agrees as a condition of certification, to indemnify, hold harmless and defend USA Cycling and its employees, officers, directors, agents, sponsors and promoters from and against all claims and expenses, including reasonable attorney fees, that in any manner arise from or relate to a certification of the individual by USA Cycling and that are asserted against or incurred by any one or more of the foregoing indemnified parties as a result of or arising from the certified individuals actions or failure to act.
COMPETING OUTSIDE THE UNITED STATES ROAD AND TRACK
In addition to an International License, a rider must obtain a Foreign Permission Letter (FPL) for each country in which a rider wishes to race (some exceptions may apply for Canada and Mexico for residents of bordering states). To obtain a FPL, submit your license information along with the names of the countries you will compete in, dates you will be overseas, foreign teams of which you will be a member, and a foreign address if available. To request an application, call 719-866-4581 or visit our website. FPLs are free for the first two. Additional letters are $10.00 each. Please allow three weeks for processing. Additional fees may be incurred for requests involving express processing or mailing.
Please initial this page and include it with your application ____________
CONTINUED ON THE NEXT PAGE
ACKNOWLEDGMENT OF RISK, RELEASE OF LIABILITY, INDEMNIFICATION AGREEMENT AND COVENANT NOT TO SUE I ACKNOWLEDGE THAT BY SIGNING THIS DOCUMENT, I AM ASSUMING RISKS, AND AGREEING TO INDEMNIFY, NOT TO SUE AND RELEASE FROM LIABILITY USA CYCLING, INC. (USAC), ITS ASSOCIATIONS (THE UNITED STATES CYCLING FEDERATION (USCF), NATIONAL OFF ROAD BICYCLE ASSOCIATION (NORBA), NATIONAL COLLEGIATE CYCLING ASSOCIATION (NCCA), AND U.S. PROFESSIONAL RACING ASSOCIATION (USPRO)) AND THEIR RESPECTIVE AGENTS, EMPLOYEES, VOLUNTEERS, MEMBERS, SPONSORS, PROMOTERS AND AFFILIATES (COLLECTIVELY "RELEASEES"), AND THAT I AM GIVING UP SUBSTANTIAL LEGAL RIGHTS. THIS DOCUMENT IS A CONTRACT WITH LEGAL AND BINDING CONSEQUENCES. I HAVE READ IT CAREFULLY BEFORE SIGNING, AND I UNDERSTAND WHAT IT MEANS AND WHAT I AM AGREEING TO BY SIGNING. In consideration of the issuance of a license to me by one or more of Releasees and being allowed to participate in a cycling event permitted or sanctioned by USA Cycling, another national federation or International Cycling Union (UCI) (collectively USA Cycling event) I hereby freely agree to and make the following contractual representations and agreements. I ACKNOWLEDGE THAT CYCLING IS AN INHERENTLY DANGEROUS SPORT AND FULLY REALIZE THE DANGERS OF PARTICIPATING IN A BICYCLE RACE, whether as a rider, coach, mechanic or otherwise, and FULLY ASSUME THE RISKS ASSOCIATED WITH SUCH PARTICIPATION INCLUDING, by way of example, and not limitation, the dangers of collision with pedestrians, vehicles, other racers, and fixed or moving objects; the dangers arising from surface hazards, including pot holes, equipment failure, inadequate safety equipment, THE RELEASEES' OWN NEGLIGENCE, the negligence of others and weather conditions; and the possibility of serious physical and/or mental trauma or injury, or death associated with cycling competition. For myself, my heirs, executors, administrators, legal representatives, assignees, and successors in interest (collectively "Successors") I HEREBY WAIVE, RELEASE, DISCHARGE, HOLD HARMLESS, AND PROMISE TO INDEMNIFY AND NOT TO SUE the Releasees and all sponsors , organizers, promoting organizations, property owners, law enforcement agencies, public entities, special districts and properties that are in any manner connected with a USA Cycling event, and their respective agents, officials, and employees through or by which the event will be held, (the foregoing are also collectively deemed to be Releasees), FROM ANY AND ALL RIGHTS AND CLAIMS INCLUDING CLAIMS ARISING FROM THE RELEASEES' OWN NEGLIGENCE, which I have or which may hereafter accrue to me, and from any and all damages which may be sustained by me directly or indirectly in connection with, or arising out of, my participation in or association with a USA Cycling event, or travel to or return from a USA Cycling event, in which I may participate as a rider, team member, spectator, coach, mechanic, official, volunteer, or in any other manner. I agree it is my sole responsibility to be familiar with the course of a USA Cycling event, the Releasees rules, and any special regulations for a USA Cycling event and agree to comply with all such rules and regulations, including, that I must submit to drug testing, if required. I understand and agree that situations may arise during a USA Cycling event which may be beyond the control of Releasees, and I must continually ride and otherwise participate so as to neither endanger myself nor others. I accept responsibility for the condition and adequacy of my competition equipment and my conduct in connection with a USA Cycling event. I have no physical or medical condition which would endanger myself or others if I participate in a USA Cycling event, or would interfere with my ability to safely participate in a USA Cycling event. I agree, for myself and my Successors, that the above representations are contractually binding, and are not mere recitals, and that should I or my Successors assert a claim contrary to what I have agreed to in this contract, the claiming party shall be liable for all expenses (including legal fees) incurred by Releasees in defending the claims. This contract may not be modified orally, and a waiver or modification of any provision shall not be construed as a waiver or modification of any other provision herein or as consent to any other waiver or modification. Every term and provision of this contract is intended to be severable. If any one or more of them is found to be unenforceable or invalid, that shall not affect the other terms and provisions, which shall remain binding and enforceable.
Signature of Applicant____________________________________________________Date_____________________________ CONSENT AND AGREEMENT OF PARENT OR GUARDIAN
I am the parent or guardian of ___________________(Child). I give permission for my Child to enter any USA Cycling event during the period of the license applied for. I HAVE READ AND I UNDERSTAND THE ABOVE CONTRACT. In consideration of allowing my Child to participate, I consent to the contract and agree that ITS TERMS SHALL LIKEWISE BIND ME, MY CHILD, my heirs, legal representatives, and assignees. I HEREBY RELEASE AND SHALL DEFEND, INDEMNIFY AND HOLD HARMLESS THE RELEASEES FROM EVERY CLAIM AND ANY LIABILITY that I or my Child may allege against the Releasees (including reasonable legal fees and costs) as a direct or indirect result of injury or death to me or my Child because of my Child's participation in a USA Cycling event, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES or others. I PROMISE NOT TO SUE RELEASEES on my behalf or on behalf of my Child regarding any claim arising from my Child's participation in a USA Cycling event.
Signature of Parent or Guardian_____________________________________________Date_____________________________
USA Cycling, Inc. * 1 Olympic Plaza, Colorado Springs, CO 80909 USA * 719-866-4581 * www.usacycling.org
