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Name
of Run
Date
SURNAME
.. FIRST NAME
..
NATIONALITY
.. AGE
DATE
OF BIRTH
SEX
ADDRESS
.
CITY
..
STATE
POSTCODE
COUNTRY
.
TELEPHONE
. FAX NUMBER
.
EMAIL
ADDRESS
.
NAME
OF CREW MEMBER
..
RUNNER
OR WALKER
.
REGO
NUMBEROF CREW VEHICLE/OR CONTRACT NUMBER FROM VEHICLE HIRE COMPANY
.
YOUR
QUALIFICATIONS TO ENTER THIS RUN
.
.
..
I
certify I have read, understood and agree to abide by the General Rules of the
..
I further understand that my crew will also be required to agree to the General
Rules and sign the Accident Waiver and Release of Liaibility/Release of Name
and Likeness form.
Signature
.
Date
Print
Name
..
Complete
this form and mail it together with signed entrant Contract and Accident Waiver
and Release of Name and Likeness forms and a check or money order for $100 AUD
by December 31st 2002 and the rest of the entry fee($400AUD) by January 30th 2003.
Please
make the check/money order payable to:
Insert
address
We
will contact you as soon as possible as to wether your entry has been accepted
or not.