REGISTRATION

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Malakoff Half Century Ride 80km

Individual Entry Form

Please complete the form below. All fields with (*) indicate are required to fill.

• Full Name : *
  as per NRIC
• Gender *
  PLEASE SELECT MALE FEMALE
• Address : *
  Street Address Address Line 2 City State / Province / Region Postal / Zip Code   Antigua and Barbuda Aruba Bahamas Barbados Belize Canada Cook Islands Costa Rica Cuba Dominica Dominican Republic El Salvador Grenada Guatemala Haiti Honduras Jamaica Mexico Netherlands Antilles Nicaragua Panama Puerto Rico Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Trinidad and Tobago United States Argentina Bolivia Brazil Chile Colombia Ecuador Guyana Paraguay Peru Suriname Uruguay Venezuela Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Faroe Islands Finland France Georgia Germany Greece Hungary Iceland Ireland Italy Latvia Liechtenstein Lithuania Luxembourg Macedonia Malta Moldova Monaco Montenegro Netherlands Norway Poland Portugal Romania San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Ukraine United Kingdom Vatican City Afghanistan Bahrain Bangladesh Bhutan Brunei Darussalam Myanmar Cambodia China East Timor Hong Kong India Indonesia Iran Iraq Israel Japan Jordan Kazakhstan North Korea South Korea Kuwait Kyrgyzstan Laos Lebanon Malaysia Maldives Mongolia Nepal Oman Pakistan Palestine Philippines Qatar Russia Saudi Arabia Singapore Sri Lanka Syria Taiwan Tajikistan Thailand Turkey Turkmenistan United Arab Emirates Uzbekistan Vietnam Yemen Australia Fiji Kiribati Marshall Islands Micronesia Nauru New Zealand Palau Papua New Guinea Samoa Solomon Islands Tonga Tuvalu Vanuatu Algeria Angola Benin Botswana Burkina Faso Burundi Cameroon Cape Verde Central African Republic Chad Comoros Democratic Republic of the Congo Republic of the Congo Djibouti Egypt Equatorial Guinea Eritrea Ethiopia Gabon Gambia Ghana Gibraltar Guinea Guinea-Bissau Cote d'Ivoire Kenya Lesotho Liberia Libya Madagascar Malawi Mali Mauritania Mauritius Morocco Mozambique Namibia Niger Nigeria Rwanda Sao Tome and Principe Senegal Seychelles Sierra Leone Somalia South Africa Sudan Swaziland United Republic of Tanzania Togo Tunisia Uganda Zambia Zimbabwe Country
• I.C No : *
  exp: 761212-10-xxxx
• Date of Birth : *
  exp: 12/12/76
• Age : *
• Tel (House) :
  exp: 03-778899001
• Tel (Mobile) : *
  exp: 015-6677889
• Email : *
• T-shirt Size : *
  S

  M

  L

  XL
• Category : *
  1. Men Open (16 -35)

  2. Men Veteran (36 -45)

  3. Men Senior Veteran (46 and above)

  4. Women Open (16 and above)
• Emergency Contact
• Emergency Contact Person Name : *
  as per NRIC
• Contact Number : *
  exp: 03-778899001 or 015-6677889
• Relationship : *
• Entry Fee

  EARLY REGISTRATION - RM90 + RM10* (deposit for timing chip) = RM100
  
  LATE REGISTRATION - RM120 + RM10* (deposit for timing chip) = RM130
  
  EARLY - payment received on or before 4th Nov 2012
  
  LATE - payment received on or after 5th Nov 2012
  
  *deposit will be refunded after timing chip handed over to the organizer.
  
  Closing Date : 11th November 2012
  
  Please make all entry fee payment to GRAND WHEELER Maybank (MBB) 5129 7800 4348 and kindly email to gw_malakoffhalfcenturyride@yahoo.com or fax over to 03-77340728 prove of payment.
  
  Organised by :
  GRAND WHEELER
  Tel :019-4249559 (Raziff)
  Fax : 603-77340728.
• Waiver

  I understand, certify that the information on this form is correct and have signed here to signify that I am in agreement with this entry, and will compete in accordance rule and regulation of the MALAKOFF HALF CENTURY RIDE 80km (MHCR).
  
  I understand that the MHCR will be a strenuous event requiring special bicycle handling skills. Which requires bicycle helmets to be worn by all participants while operating bicycle and there is NO exception to this requirement. I by agree that to participating in this event and voluntarily assume such risks.in consideration of being permitted to participate in this event:
  
  1) I release for myself, my heirs,and personal representatives, and the undersigned registrant under age 18(minor) . GRAND WHEELER, and their respective,officers,volunteers, sponsors and staff(indemnities) from any claim,liability,demand,action,and cause of action whatsoever(collectively, “claim”)arising out of this event;
  
  2) if registered as a minor, I (as a parent a guardian) agree to indemnify and holdharmless each indemnities against any claim for any lost;
  
  3) consent to emergency medical treatment if I am injured;
  
  4) shall obey traffic laws and practice safety in bicycling.
  
• Authorization by parent/guardian of participant under 18 years old.

  I (as name below), as parent/guardian of participant of the above named, authorized his/her participation in the MALAKOFF Half Century Ride 80km (MHCR).
• AGREE
• Name :
  Parent/Guardian name
• I.C No. :
  exp: 761212-10-xxxx
• Relationship to participant below 18yrs :
• Are you a member of any Cycling Club/Sports Club?

  If yes state name of Club
• Notice: This entry and release form is contract with legal consequences upon signing. For online registrations, submitted form considered agreed.