2009 LICENSE APPLICATION
Individual Racing License (19 and older) ………………………………. $ 45.00
Junior Racing License (8-18) ………………………..……………….….. $ 15.00
Family (one household; no room-mates) …….……..………………....... $ 75.00
Official Only or Mechanic Only ………………………….………….….. $ 20.00
Combined Racer & Official/Mechanic ………………….…..…………… $ 45.00
Non-Racing/Recreational ……………………..…………………………… $ 25.00
Fees above are for Unattached riders or ACA Club Affiliated riders.
To have results/license reflect a Non-ACA registered club ADD $20.00
PLEASE
PRINT Donation to ACA Junior Development Fund $ _____
TOTAL (Check # ____________ Cash _____) $ _______
LEGIBLY
Previously paid one-day fees can not be applied towards an annual license.
Name ________________________________ ____________ Date of Birth ____/____/____
Last Name First Name
Resident of Current State Since ____(m) /______(yr) Racing Age _________
as of 12/31/09
Address _____________________________________________________ Apt/Unit # ___________
City______________________________________ State ______ Zip Code _________________
Home Phone ____ - _______________________ Work Phone ____ - _____________________
Cell Phone ____ - _______________________
Email Address ____________________________________________________________________
Please include your email address so our office can send you a PDF of your license. ACA uses the email address to send racing
announcements, to conduct surveys, to send invitations to racing related events. We will not share, sell or give your email to
anyone else. If you do not want to receive any information by email from ACA other than your license PDF please check
here__________
ACA Club Number _______ (on ACA website/newsletter)
Team Name ________________________________________________________________
If team is not registered with ACA, you will be listed as Unattached unless an additional $20 is included with application.
Emergency Contact _______________________________________ Phone ____ - ____________
Renewing ACA Member? YES____NO____ 2008 ACA License # ___________________
USAC License? If yes, #_____________ Category: ___RD ___TK ___CX _____MTB-CC
Class (Circle) Senior Men Senior Women Junior Men Junior Women
(over 18) (over 18) (8-18) (8-18)
Circle Appropriate Category (Experience Level : Beginner Intermediate Regional National Professional )
Road Classification 4 3 2 1 Pro
Track Classification 4 3 2 1 Pro
Cyclocross Classification 4 3 2 1 Pro
Mountain Bike Cross-Country 3 (Beg) 2 (Sport) 1 (Expert/SemiPro) Pro
IF YOU HAVE NEVER HELD A LICENSE BEFORE YOU WILL BE CATEGORIZED AS A “4” in RD,TK, CX and a “3” in MTB
IF YOU ARE JOINING FOR THE FIRST TIME BUT HAVE ANOTHER ASSOCIATION'S LICENSE PLEASE ATTACH COPY TO BE
CATEGORIZED ACCORDINGLY.
LICENSES WILL NOT BE ISSUED TO RIDERS UNDER THE AGE OF 8.
Senior Age Declaration for BAR and BCR: 35+ 45+ 55+ 65+
In combined category BAR/BCR races, if you intend to race in a younger age classification circle the appropriate age
Officials Classification Rd___ TK ___ MTB____ USAC/UCI_____
Mechanic Classification 4 3 2 1
Signature ________________________________________________ Date _________________
All licenses expire on 12/31/09. Those purchased after Nov 15th, 2009 will be valid through 2010.
Please Send to: Yvonne van Gent, AMERICAN CYCLING ASSOCIATION,
1135A So Oneida, DENVER, CO 80224
PLEASE ATTACH CHECK PAYABLE TO AMERICAN CYCLING ASSOCIATION
