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Registration form

YOU CAN EITHER MAIL THIS to3-2, Jalan PGN 1A/1, Pinggiran Batu Caves, 68100 Batu Caves, Kuala Lumpur OR FAX TO 03-61888734 OR E-MAIL TO info@wiraconsultant.com. We can be contacted at 03-6188 0005 or 012-481 2005 or 012-335 6005

REGISTRATION FORM

  

Name of expedition or trip :______________________________________________________

Date :__________________ days:________ nights :________

Name (Mr/Ms/Mdm) :_________________________________________________________ (As in your IC or passport)

Identity Card No/Passport No :_________________________

Date of Birth :______________

Correspondence address :

  

Office telephone number :____________________________
House telephone number :____________________________
Fax / E-mail address :_______________________________

Name of next of kin, address & contact number :

  

IMPORTANT : Please state if you have any medical ailment/ medical history we should know about such as asthma/ulcer and others.

I enclosed herewith my expedition/trip deposit/full fee of RM_________which is
non-refundable in Cash/Postal Order/Bank Draft made payable to WIRA ADVENTURE CONSULTANT, account number 3070342910, Public Bank Berhad.

I hereby agree to abide by all the rules & regulation laid down by the organisers and will not claim any damages from the organisers in the event of any accident, injury or death which arise before, during or after my participation.

Participant’s signature :_________________

Registration Form (printable page) - On Line Registration Form