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Kamennoostrovsky pr., 197022 Tel/Fax: +7- 812 - 234-5432 http://www.wdr.ru/eng WHEELCHAIR DANCE SPORT Continents Cup 2010 ENTRY FORM ENSEMBLES Please, indicate who is wheelchair user (Yes/No) Participant Participant Name / Surname: Name / Surname: Name / Surname: Name / Surname: Name / Surname: Name / Surname: Name / Surname: Name / Surname: Nation: City: Contact person: Address: Tel: Fax: E-mail: Date: Signature and stamp ( ) The Entry Form should be sent by e-mail or fax no late.

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