G20 LANGKAWI RIDE 2009

(07TH MAC – 10TH MAC,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/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 Langkawi 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 pillon. 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 : affian71@gmail.com
affian71@yahoo.com

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