8/8/2019 Entry Form Green Fun Run
1/1
DATE : 27 NOVEMBER 2010 For Official Use only
TIME : 7.00 AM TO 1.00 PM (Registration at 6.30 am) Receipt No :
________________
VENUE : NEOCYBER, CYBERJAYA RM Cash / Cheque
CLOSING DATE : 22 NOVEMBER 2010 Issued By :
__________________
Category : __________________
FULL NAME ( BLOCK LETTER ):
I/C NO : SEX :
DATE OF BIRTH : AGE : TELEPHONE NO :
- - -
MAILING ADDRESS:
POST CODE : NATIONALITY :
EMAIL ADDRESS :
RACE CATEGORY (PLEASE TICK ONE ONLY):
Reg. Fee
Men Open 18 and above
Women Open 18 and above
Men Veteran 50 and above
Women Veteran 50 and above
Corporate All ages
Men (13 - 17) 13 - 17
Women (13-17) 13 - 17
EVENT TEE SIZE : S M L XL XXL XXXL
( Note : Please tick. Size subject to availability while stock
last )
WAIVER CLAUSE
In consideration of the Organizer accepting this entry, and
registration to participate in the above Run, I hereby waive and
release any and all right or claims to
damages I may againt the Organisers holding this Run, their
agents, representatives, successors, assigns, race sponsors for any
and all injuries, death and
invalidity I may sustain before, during or after the course of
the event or arising as a result of it. I hereby indemnify the
Organisers and keep them indemnified and
waived againts all calims or damages that arise in consequence
of the above.
Signature of participant : Date :
FOR PARTICIPANTS UNDER 18 YEARS
I, i.c No parent/ gurdian of the participant, whose particulars
appear
above, confirm that I fully understand and appreciate the effect
of the above waiver and hereby agree and declare on behalf of the
participant That the
Waiver Clause will have been binding affect on the participant.
I hereby consent to his/her participation in the Run as stated
above.
Signature of Parent/Guardian : . Date : .
Laketown Sdn Bhd Date : 24,25,26 Nov 2010 Tel : 03-7722 3830 (
Azah Razman )
3A-G NeoCyber, Time : 9.00 am to 5.00 pm Fax : 03-7710 3966
Lingkaran Cyber Point Barat At Laketown Sdn Bhd (Sales
Gallery)
63000 Cyberjaya, Selangor Darul Ehsan 3A-G NeoCyber
Lingkaran Cyber Point Barat
63000 Cyberjaya, Selangor Darul Ehsan
OR
FAX AT 03-77103966 Email : [email protected]
Website : www.emkay.com.my
MBB Account no : 012204208039
RM20
RM20
RM20
Registration
& paymentT- Shirt Collection Contact Number
7km
7km
10km
7.45am
7.45am
7.30am
7.30am
7.30am
REGISTRATION FORM
REMARKTICK
RM20
7km
7km
RM250
RM10
RM10
7.45am
7.45am
C
D
E
F
G
Code
MALE FEMALE
A
B
Category Age Distance
10km
10km
Start Time
mailto:[email protected]://www.emkay.com.my/http://www.emkay.com.my/mailto:[email protected]
