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, 2010
RM90/ - 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 organizing
committee 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 my
identity card/Passport.
3. I have read and agree to abide by the Rules & Regulations of the 1 st Malacca Malaysia International12 Hour Walk
2010.

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 PERSEKUTUAN

2nd Floor, Wisma OCM, Jalan Hang Jebat, 50150, Kuala Lumpur, Malaysia.