G20 Pattaya Ride 2009

G20 PATTAYA RIDE 2009 (29TH APR – 4th MAY,2009) REGISTRATION FORM (PLEASE FILL IN PARTICULARS) NAME OF RIDER (AS IN NRIC NO/PASSPORT):_____________________________________ DATE OF BIRTH :___________

SEX :___________

NATIONALITY : ______________

TEL : (RES)________________ TEL (OFF)________________ (HP)______________________ NRIC/PASSPORT NO :___________________________ BLOOD GROUP :________________ T-SHIRT SIZE(S/M/L/XL/XXL/3XL/4XL)___________ DRUG ALLERGY (IF ANY)____________ PAYMENT : RM _____________

MOTORCYCLE PARTICULARS : REGISTRATION NO : _______________ MAKE & MODEL : ____________________________ ENGINE NO : ______________________ CHASSIS NO : ______________________________ ENGINE CAPACITY : ________________________ YEAR MADE : ______________________ ROADTAX EXPIRY DATE : _______________ LISENCE EXPIRY DATE : ________________ *** PHOTOCOPY OF REGISTRATION CARD/ ROAD TAX/ LISENCE/ NRIC OR PASSPORT NO AND IF UNDER FINANCE LETTER OF AUTHORIZATION FROM FINANCE CO.

PERSON(S) TO CONTACT IN CASE OF EMERGENCY: NAME :____________________________________ ___ CONTACT NO : _________________ RELATIONSHIP : ______________________

DECLARATION & INDEMNITY I/we declare that the information provided above is true on the best of my/our knowledge. I/we further declare that I/we willingly participate in the G20 Pattaya Ride 2009 (herein after, referred as “the event”) voluntarily. In consideration of your allowing me/us to participate in the above mentioned event, I/we hereby warrant that I/we will indemnify and safe harmless including but not limited to its members and respective officials from the against all actions, claim, cost, expenses, demands, liabilities, injuries ,negligence and judgements including legal fees (on a solicitor-client basis) in respect of death or injury to myself/ourselves and damage of property belonging to me/us or others howsoever caused arising out of all in connection with my/our taking part in the above-mentioned event as a rider or pillion. I/we further warrant that I am/we are in good health, am/are over 18 to possess a valid riding license (applicable to riders only) and the standard of competence and experience expected of participations for the event.

______________________________

Application approved/ reject

Signature of Rider / Date

_____________________ Signature Please contact : Zahida Ismail (+60192840200) Affian (+60172058777) e-mail : [email protected] [email protected]

**** G20 SECRETARIAT HAVE THE RIGHT TO REJECT ANY APPLICATION WITHOUT ANY WRITTEN REASON