EmailMe Form - BMT - Beat My Trick 2012 (5-7 Oct )

Name *

First Last

IC No *

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

Category *

Email *

T-Shirt Size

RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY

AUTHORISATION BY PARENTS/GUARDIAN OF PARTICIPANT UNDER 18 YEARS OLD

Registration fee : RM15.00 per person
Any Inquiries : 0129460468 (Joe) 0169900804 (Rizal)
http://www.facebook.com/events/370056643063688/