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 : affian71@gmail.com
affian71@yahoo.com

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