Record / Trace No.

MAH AM AS

LARIAN GEMILANG MAHAMAS

Events

2014

Official Entry Form

Sunday, 4th May 2014

One person per entry form, form may be duplicated. NO REFUNDs OR TRANSFERS
Course The Fun Run/Walk will begin and end at Tapak C, Taman Tasik Permaisuri, Bandar Tun Razak, KL. It is a 5 KM route. The paved course is mostly flat with some inclines and declines. A water station and first aid kit will be available.

8:00 AM - Adult Fun Run (5KM)

Entry Fee: RM

20.00

NAME AS PER NRIC / PASSPORT

GENDER M F AGE BIRTHDAY (MM/DD/YYYY) T-SHIRT ADULT SIZE (Unisex) S M L XL 2X

EMAIL (Email required to get prerace updates.) STREET ADDRESS CITY DAYTIME PHONE EVENING PHONE STATE POST CODE

) (

RACE DAY EMERGENCY CONTACT PHONE

RACE DAY EMERGENCY CONTACT NAME

MUST BE SIGNED BY ALL PARICIPANTS: DECLARATION (1) I, in completing this registration, in consideration of and as a condition of acceptance of my entry in the Larian Gemilang Mahamas (the Event) for myself, my heirs, executors and/or administrators (We) hereby waive all and any claim, right or cause of action which We might otherwise have arising out of death or injury, damage or loss of any description whatsoever I may suffer or sustain in the course of, or consequent upon my entry or participation in the Event. (2) This waiver, release and discharge shall be (and operate separately) in favour of all persons, corporations and bodies involved, or otherwise engaged in promotion or staging the Event and each of their servants, agents, representatives and officers. (3) I agree to read the rules and regulations and conform to them (if I am under the age of 18 my parent or guardian has signed below). (4) Entry fee is not refundable in all circumstances, including cancellation of the Event.

I________________________________________________________ (NRIC / Passport: ________________________) certify that I have read and understood the above declaration of indemnification that applies to myself as a participant in the Larian Gemilang Mahamas (the Event). I hereby agree to abide by its terms. If you are under the age of 18 on the day of the Event Date, your parent or guardian must agree to this declaration. I _______________________________________________________ (NRIC / Passport: _____________________) certify that I am the parent/legal guardian of _______________________________________________________ and she / he has my consent to participate in the Larian Gemilang Mahamas (the Event) on Sunday, 4th May 2014. I understand the disclaimer above shall apply to him / her and join in such indemnification. Signature:____________________________________________________ Date : _____________________________________

DECLARATION

Rules, Regulation & Notification:-

1. Age Qualification: 13 and above 2. Fee: RM 20.00 / Participant which inclusive of: Event T-shirt, Goody Bag, & Light Refreshment 3. Registration & prove of Payment have to be sent to:Maha Mas Medic Services Sdn Bhd No. 6, Jalan Pahang Kecil, 53200, Kuala Lumpur Fax : +603 4022 9044 Email : lariangemilangmahamas@gmail.com 4. Maybank Account No: 5144 - 770 - 18449 5. Collection of T-Shirt Date / Time : 4th May 2014 /6.00 am to 7.30 am Location : Tapak C, Taman Tasik Permaisuri 6. Closing Date 25th of April 2014 or upon receiving 1,500 entries. 7. For more Info, please contact:Mobile : +6010 - 5080 648 email : lariangemilangmahamas@gmail.com 8. Technical Manager - Julie Wong - +6016 228 4088

REGISTRATION SLIP
PAYMENT SUM PAYMENT METHOD NAME AS PER NRIC NRIC NO. PAYMENT DATE : RM 20.00

Record / Trace No.

Kindly retain this slip as proof of registration. This Slip must be shown to the Organizer when requested. : CASH / CHEQUE / BANK TRANSFER / OTHER : ___________________________________________ : ___________________________________________ : ________________

AUTHORIZED SIGNATURE : ___________________________________________

Note: 1. Kindly retain proof of payment for payment method(s) other then CASH 2. Event T-shirt is given on the basis of availability. If the requested size is unavailable, the nearest available size will be given instead.