Transcript Deelname Formulier 13 Srefidensi Marathon 2016

Deelname Formulier 13e Srefidensi Marathon 2016
Zaterdag 19 november om 17.30 u n.m.
SURINAME
Srefidensi Marathon Paramaribo
Adres : Luchtmacht Basis, Doekhieweg, Zorg en Hoop
Paramaribo, Suriname
Telefoonnummer:(597)478059 / mobiel:8611614/ 8856902
Email : [email protected] / [email protected]
Voorzitter: Majoor R.Samuels 00597-8611614
[email protected]
□m
□v
Naam + voornaam : .........................................................
Geslacht
Adres:
...............................................................
leeftijd ..............................
Telefoon:
...............................................................
Nationaliteit: ...................
Categorie:
□ Marathon
□
□
□
½ Marathon
Registratie fee
200 SRD
Medische keuring
□ja
□ nee
100 SRD
datum..................
Ekiden voor senioren
Business estafette
Anderen
arts: .......................
350 SRD
150 SRD
½ Marathon estafette
150 SRD
handtek:.................
Te storten op de Hakrinbank t.n.v. Srefidensi Marathon op rek no: 20 644 01 26 tot uiterlijk zat. 12 november ‘16
Deelnemers Ekiden
Senioren
1. .............................
2. .............................
3. .............................
4. .............................
5. .............................
6. .............................
Reserve: .............................
Deelnemers ½ Marathon
Junioren
1. .............................
2. .............................
3. .............................
4. .............................
Reserve:
n.b. deelname aan dit evenement is geheel op eigen risico en eigen verantwoordelijkheid.
Handtekening:..................................
Registration Form 13th Srefidensi Marathon 2016
Date: Saturday november 19th at 17.30 u.
SURINAME
Srefidensi Marathon Paramaribo
Adres : Luchtmacht Basis, Doekhieweg, Zorg en Hoop
Paramaribo, Suriname
Telefoonnummer: (597)478059 / mobiel:8611614/ 8856902
Email : [email protected] / [email protected]
Voorzitter: Majoor R.Samuels 00597-8611614
[email protected]
Name + surname : ............................................................
□ male
Adres: .................................. country.............................
date of birth ..............................
phone: ................................. e-mail ..............................
Nationality: ...................
Category:
Statement
□ Marathon
□ ½ Marathon
□
□
Registration fee
□ female
Medical
( 40 U$/ Euro 30 )
□ yes
(25 U$/ Euro 20 )
date: .........................
Ekiden for senior athletes
Business estafette
Others
( 80 U$ )
( 40 U$ )
½ marathon
( 40 U$ )
□ no
Please deposit the amount on the account of the Srefidensi Marathon Commission : Hakrinbank no: 20 644 01 26
not later than Saturday november 12th 2016
Participants Ekiden
Senior Athletes
1. .............................
2. .............................
3. .............................
4. .............................
5. .............................
6. .............................
Reserve: .............................
To take part in this event is at my own risk and responsibility.
Junior athletes
1. .............................
2. .............................
3. .............................
4. .............................
Reserve: .............................
Signature: ....................................