Your Full Name	:
Your Telephone Number	:
Your Email Address	:
Type of Event	:	Cycle Race Mountain Biking Event Cross Country Race Triathlon Marathon Charity Event Escort Service Other ... I'm not sure
If other, please state	:
Please provide us with an outline of the event.	:
Duration of Event	:	1 day 2 days 3 days 4 days 5 days More than 5 days I'm not sure
How many participants are you anticipating?	:	1 to 50 51 to 100 101 to 200 201 to 500 501 to 1000 More than 1000 I'm not sure
Would you require medical cover for the event?	:	Yes - contact me with more information Yes - but I need some advice No - we already have cover organised No - cover not required
Is this an event we have previously covered?	:	Yes - NEG Wales have covered this event before No - It hasn't been covered before by NEG Wales I'm not sure
Please provide us with any other information about this event, that hasn't been mentioned elsewhere in this form	:

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