* Declaration
* Address / Alamat
(Please make sure address is complete in order to receive your certificate)
Allianz Penang Bridge International Marathon
18 November 2012
I,
(Name)
Organised by Penang State Tourism Development & Culture
www.penangmarathon.gov.my
(NRIC / Passport No.)
Entry Form / Borang Pendaftaran
read the Rules & Regulations and I agree to participate on the understanding that, I will adhere to ALL Rules & Regulations stipulated at www.penangmarathon.gov.my Please complete this Entry Form in Block Letters
* Name / Nama (as in NRIC / Passport)
City /
Bandar
:
Postcode / :
Poskod
State /
Negeri
Country / :
Negara
WAIVER CLAUSE : In consideration of the acceptance of my entry, I, my heirs, successors and assigns, do hereby unconditionally waive and release the organisers, this marathon event sponsors and all persons and agencies connected with it from all claims and damages whatsoever, that may arise from my participation in this event, including without limitation, personal injury.
:
Home / Office Tel. No. :
Tel. Rumah / Pejabat
* Email Address / Alamat Emel
(For race confirmation and future event communication)
Mobile No. / Tel. Bimbit :
...............................................
Participant's Signature
Nationality / :
Warganegara
T-Shirt / : S
Vest Size
* Female / Perempuan:
D
M
M
XXXL
(Participant's name)
Age / Umur
* Date of Birth / Tarikh Lahir
D
XXL
PARTICIPANTS BELOW THE AGE OF 18 YEARS OLD ARE
REQUIRED TO COMPLETE THIS SECTION
L
T-Shirt / : XL
Vest Size
* Gender / Jantina: Male / Lelaki:
M
Y
Y
Y
Y
Self Collection at
Queensbay Mall :
(NRIC / Passport No.)
10th and 11th Nov 2012 (10am to 9pm)
14th and 16th Nov 2012 (10am to 9pm)
Parent / Guardian
17th Nov 2012 (10am to 6pm)
* NRIC / Passport No. / No. KP / No. Pasport
I,
(Name)
* Running Categories
Full Marathon (42km)
Men’s Open (18 years old & above)
Women’s Open (18 years old & above)
Men’s Veteran (40 years old & above)
Half Marathon (21km)
Men’s Open (16 years old & above)
Women’s Open (16 years old & above)
Men’s Veteran (45 years old & above)
Women’s Veteran (35 years old & above)
Please indicate your Health History
High Blood Pressure
Yes
Heart Disease
Yes
No
Diabetes
Yes
No
Allergies
Yes
(NRIC / Passport No.)
No
No
Please state if Yes
__________________________
hereby consent to my child / ward participating in the PBIM 2012. I have read and agree to the Rules and Regulations of the PBIM 2012 which states that the participant will run at his / her own risk and the
Organisers will not be held responsible or liable for any injury or death howsoever arising from training for or during participation in the marathon. ................................................
Parent or Guardian's Signature
Please indicate your Emergency Contact
10km Run
Boys’ (13 to 17 years old)
Girls’ (13 to 17 years old)
Men (18 years old & above)
Women (18 years old & above)
Name :
Fun Run (10km)
13 years old & above (born in 1999 or earlier)
Contact No. :
Official School Stamp
Entry forms submitted by school-going participants must be endorsed by their principal Relationship : Spouse
Siblings
Friends
Others
Relatives
Principal's Signature ..............................................................
Cash prizes up for grab for top 3 schools with most number of participants.
Cash prizes as follow:
1st Prize: RM 1,000
2nd Prize: RM 800
3rd Prize: RM 600
MODE OF PAYMENT :
Online payment via Master / Visa and major banks onlines transfer are available at www.penangmarathon.gov.my Entry form, detailed information, rules & regulations of Penang Bridge International Marathon are posted at www.penangmarathon.gov.my
The decision of the organising committee to accept entries is final. No refund will be made for wrong or multiple entries. Incomplete entry forms will not be accepted.
Event Information
: 18 November 2012 (Sunday)
Date
End Point : Queensbay
Enquires : 016-411 0000
: info@penangmarathon.gov.my
Email
Start Point
Website
Hotline Hours
Closing Date
: Queensbay
: www.penangmarathon.gov.my
: Monday to Friday, 10am - 6pm
: 15 October 2012
Mode of Registration :
Register online at www.penangmarathon.gov.my
You may obtain and submit your Entry Form at these PBIM registration counters :
- Penang Tourism Development & Culture Office
Level 53, Komtar 10503 Penang.
Tel: 04-650 5136
(Monday to Friday, 9am - 5pm)
Fax: 04-261 8744
- Information Kiosk
Ground Floor, Komtar, Penang
(Monday to Friday, 10am to 5pm)
Race pack collection : Please bring PBIM Official Receipt / Confirmation Slip / IC or Passport.
Registration Fees
Normal Fee (1/6 - 15/9/2012)
Early Bird (28/4 - 30/5/2012)
Full Marathon
RM 60
Full Marathon
RM 80
Half Marathon
RM 45
Half Marathon
RM 60
10KM Open
RM 40
10KM Open
RM 50
10KM Junior
RM 30
10KM Junior
RM 40
Fun Run
RM 15
Fun Run
RM 20
Late Registration (16/9 - 15/10/2012)
Full Marathon
RM 90
Half Marathon
RM 80
10KM Open
RM 70
10KM Junior
RM 45
Fun Run
RM 30
www.penangmarathon.gov.my
Penang State Tourism Development & Culture Office 