1st malacca 12 hour walk (entry form)
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8/9/2019 1st Malacca 12 Hour Walk (Entry Form)
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ENTRY FORM
1st MALACCA INTERNATIONAL 12 HOUR WALK 2010
Start: December 11, 2010 – 2000 hours (Sat) Registration Fee: 2 in 1 Package [12 Hour + 50km]
Ends: December 12, 2010 – 0800 hours (Sun) RM70/ - Before October 15, 2010RM90/ - Oct 16 to Nov 15, 2010
Closing Date: December 1, 2010 RM120/- 16 ~ 30 Nov, 2010 (Late Entries)*PLJKM Members are entitle for RM10 discount
Chip Deposit RM20/- (Refundable) – Please pay during the day of number collection
INDIVIDUAL ONLY
Name: …………………………………………………………………………………………………………….(According to Identity Card/Passport only)
IC/Passport No. ……………………………………………………
Age as at December 31, 2010 ………… Date of Birth ……………. Sex: Male / Female
Address:………………………………………………………………………………………………….…………….
……………………………………………………………………………………………………………….............
Country: ………………………. Post Code: ……………. E-mail address: …………………………..........
Tel. No : …………………...... Mobil Phone No.……………………..... Fax No. ……………………...
Please indicate Category entered: -A – Men Open: 12 Hour Walk + 50km (All included in 1 entry fees)
B – Women Open: 12 Hour Walk + 50km (All included in 1 entry fees)
Contact Person in case of Emergency: ……………………………………… Phone Num: ………………..
Any previous participation in competitive walking events? Yes / No
If Yes, provide details …………………………………………………………..………………………
Declaration:
1. I hereby declare that I am medically fit and I am entering this event at my own risk and will not hold the organizingcommittee responsible for any injuries for accidents which may incur before, during and after the event.
2. I declare that my age is above 18 years of age and correctly calculated against the date of birth stated in myidentity card/Passport.
3. I have read and agree to abide by the Rules & Regulations of the 1st Malacca Malaysia International12 Hour Walk2010.
Signature: ………………………………………… Date: ……………………………
Enclosed herewith Cash/Money Order/Cheque No. ………………………. for RM ………………………..
Bank in Account : Page 3, Rules & Regulation ref. no 23
Entry forms send to: PERSATUAN LUMBA JALAN KAKI MALAYSIA,
No. 39, Jalan SS 5A/6, 47301, Petaling Jaya, Selangor D.E. Malaysia.Tel: 019-9345106 Fax: 03-8736 5436
PERSATUAN OLAHRAGA AMATUR WILAYAH PERSEKUTUAN2nd Floor, Wisma OCM, Jalan Hang Jebat, 50150, Kuala Lumpur, Malaysia.