To the team manager: (PLEASE USE BLOCK CAPITALS and include your name in the list) (1 to 5 if are a rider)

Date: Please accept the rider(s) listed Below representing Team: Category Number of rider Entered: I enclosed the bank in slip for the sum of RM
Sunday, 15th September 2013 Pantai Batu Burok, Kuala Terengganu

NB: if you wish to register for more than 5 riders please make photo copy: 1 Name Email 2 Name Email 3 Name Email 4 Name Email 5 Name Email Nationality DD D.O.B Nationality DD D.O.B Nationality DD D.O.B Nationality DD D.O.B Nationality DD D.O.B MM YY I.C/passport No: Gender Male Female MM YY I.C/passport No: Gender Male MM YY I.C/passport No: Gender Male Female MM YY I.C/passport No: Gender Male Female MM YY I.C/passport No: Gender Male Female

Jersey Size XS S M L XL XXL

1. Under 18 (Men) 2. Men Open (18-35) 3. Men Veteran (36-45) 4. Men Senior Veteran (46 and above) 5. Women Open (18 and above)

Female

WAIVER: I, The undersign, 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 TERENGGANU CENTURY RIDE (TCR) 2013. I understand that the TCR 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 here by agree that to participate in this event and voluntarily assume such risks.in consideration of being permitted to participate in this event: 1) I /they release for myself/themselves, my/their heirs and personal representatives, and the undersigned registrant under age 18(minor) . Pedal Explorer, and their respective, o cers, volunteers, sponsor and sta (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 hold harmless each indemnities against any claim for any lost; 3) consent to emergency medical treatment if I am injured; 4) shall obey tra c laws and practice safety in bicycling.

Team Managers Name: Managers Address: City: Postcode: D.O.B

Day

Month

Year

Age

Country: Telephone No:

Email address: Mobile Phone No:

(All entry fees make payable to ZULKARNAIN SHAH. MBB: 104068135152 Organised by Pedal Explorer (pedalexplorer@yahoo.co.uk) Tel: 016-6332457 (Zul) & 017-2960786 (Shiman) Fax: 03-89964597

Entry Fees:

01/07/2013 - 15/08/2013: RM100.00 | 16/08/2013 - 30/08/2013: RM120

Signature: Date: NRIC/Passport No:

Closing Date: 30/08/2013 Online Registration: