Download Registration Foam Songkhla Bike Week 1

 RIDE TO SONGKHLA BIKE WEEK 30-­‐1 Feb. 2015 Registration Fees: RM 50 per rider RM 150 per pillion ( Optional : RM15 for Thai Insurance & White Card ) -­‐ Ducoment : Grant Copy Closing Date: 20/12/2014 REGISTRATION FORM (PLEASE FILL IN ALL PARTICULARS) Name of KTM CKD Owners Club :_________________ Name of Rider (As in NRIC):___________________________________________________________________ NRIC No: ____________________________________Sex: _______________ T-­‐Shirt Size (S/M/L/XL): _______ Address: __________________________________________________________________________________ __________________________________________________________________________________________ Contact -­‐ Res: ______________________ Off: ______________________ H/P: __________________________ E-­‐mail: ____________________________ Passport No: ____________________ Expiry On: _______________ Blood Group: _________ Drug Allergy (if any): ____________________________________________________ Name of Passenger (As in NRIC):_______________________________________________________________ NRIC No: ____________________________________Sex: _______________ T-­‐Shirt Size (S/M/L/XL): _______ Address: __________________________________________________________________________________ __________________________________________________________________________________________ Contact -­‐ Res: ______________________ Off: ______________________ H/P: __________________________ E-­‐mail: ____________________________ Passport No: ____________________ Expiry On: _______________ Blood Group: _________ Drug Allergy (if any): ____________________________________________________ KTM BIKE PARTICULARS -­‐ Registration No: ____________________ KTM Model: _______________________ PERSON TO CONTACT IN CASE OF EMERGENCY -­‐ Contact No: _______________________ Name: _________________________________________________ Relationship: _______________________ DECLARATION & INDEMNITY I declare that the information provided above is true to the best of my knowledge. I further declare that I willingly participate in the KTM MALAYSIA CKD Ride to SONGKHLA BIKE WEEK 2015 (hereinafter, referred to as “the event”) voluntary. In consideration of your allowing me to participate in the above mentioned event, I hereby warrant that I will indemnify and safe harmless KTM Malaysia-­‐CKD including but not limited to its members, respective officials and/or sponsors and those connected with the event from against all actions, claims, cost, expenses, demands, liabilities, injuries, negligence and judgments including legal fees (on a solicitor-­‐client basis) in respect of death or injury to myself and damage to property belonging to me or others however caused arising out in all connection with my taking part in the above-­‐mentioned event as a rider or passenger. I further warrant that I’m in good health, holding a valid driving license (applicable to the riders only) and the standard of competence and experience expected of participants for the event. I agree without payment on royalties of any kind, to have my photographs and/or video taken and used, re-­‐used, published and re-­‐published in any form deemed appropriate, in relation to the event. __________________________ __________________________ Signature of Rider S ignature of Passenger Date: Date: Itinerary Detail Please contact: AMIR 016-­‐4508319 or FAZURA 016-­‐4201726 Payment Mode: Cash / Cheque No: ________________ RM _______________ Receipt No: ________________ Bank Acct No : MBB 552022-­‐602382 EUROTECH WHEEL DISTRIBUTION SDN BHD (Send your bank in slip copy to [email protected])