Competition No

ENTRY FORM

NOVICE
REGULAR 15th October 2011

Team Name:

PARTICULARS
Vehicle Registration Road Tax Expiry Date
No
Driver: Navigator:
Mr/Ms/Mdm Mr/Ms/Mdm
H/P No H/P No
Off No Off No
E-mail E-mail

Passenger 1: Passenger 2:
Mr/Ms/Mdm Mr/Ms/Mdm
E-mail E-mail

DECLARATION
In consideration of the acceptance of our entry, we, the undersigned, hereby agree to abide by the Rules and Regulations of the CITY REVIVAL CHARITY HUNT
2011 ("the Hunt") and to indemnify and save harmless City Revival Community Services Bhd, the Sponsors of the Hunt, the Federal and State Governments of
Malaysia and all other person or persons how so ever connected to or involved with the organisation or conduct of the Hunt and their respective servants or
agents from all actions, claims, costs and damages in respect of death or injury to the any of us or damage to our property how so ever caused arising out of
our taking part in the Hunt notwithstanding that such death, injury or damage may have been contributed to or caused by the negligence of the aforesaid
bodies, their servants or agents. We further declare that all the information given in this Entry Form is true and complete

Driver ………………………………………….…………… NRIC …………………………..………………… Signature ……………………..……………………

Navigator …………………………………….…………….. NRIC ……………………………..……………… Signature ………………………..…….……………

Passenger 1 ……………………………………………….. NRIC ……………………………………..……… Signature ………………………………..….………

Passenger 2 ……………………………………………….. NRIC …………………………………..………… Signature ………………………………..………….

EMAIL crcsb@cityrevival.org.my OR FAX TO 03-56361545 THIS FORM TOGETHER WITH THE CASH DEPOSIT SLIP AFTER YOU HAVE DEPOSITED
CASHPassenger
INTO “CITY 2………………………………………… NRICMALAYAN
REVIVAL COMMUNITY SERVICES BHD’s” ………………………………………...Signature …………………………….
BANKING ACCOUNT NO 512307006996. Please attention the deposit slips
to S.Ravind (012 -206 9091)
st
Participants Entry fees: Early Bird Registration by 1 August 2011 : RM 60 each X ….….…..
Normal Registration : RM 70 each X ………....

Total payable RM ………..

For Official use only: Received by: Date Receipt No Remarks