IPMARace 2011: REGISTRATION FORM

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INSTITUT PENDIDIKAN MARA Race 2011 IPMARace 2011 REGISTRATION FORM A (PER TEAM) 10th - 12th June 2011, Melaka International Motorsports Circuit (MIMC), Melaka All participants are required to submit the registration form before 31st March 2011. Institution Name -Complete Address - Tel. No. - Fax. No. Team Name Team Manager (Academic / Staff) Technical Advisor (Academic / Staff)

1. 2. 3. Driver Name 1. (Student) 2. Team Member 1. (Student) 2. - Exclude the driver 3. 4. 5. 6. 7. 8. *** Maximum team member is 14 person. 1. The institution is necessary to have their own team name (For example: IKMJ Racing Team). Please email to us if the team have additional logo other than the institution’s logo. 2. All racing team is required to email a team photo (posing in front/side/behind the racing car if possible) for the event book. 3. Each institution can send at least one name of the driver and he/she must be 18 years old on 9th June 2011. 4. All the team members must bring the IC/Passport/Student Card/Staff Card for the purpose of registration. The registration starts from 2.00pm till 6.00pm on the 9th June 2011 at Melaka International Motorsport Circuit (MIMC) Ayer Keroh, Melaka. Please fax your participation form to us to: En. Md. Shafiee bin Mohd Noh (Pendaftaran & Penyertaan IPMARace 2011, IKM Jasin, Melaka) Tel: 06 - 529 1561 Fax: 06 - 529 2561 Email: [email protected]

IPMARace 2011: REGISTRATION FORM

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INSTITUT PENDIDIKAN MARA Race 2011 IPMARace 2011 REGISTRATION FORM B 10th - 12th June 2011, Melaka International Motorsports Circuit (MIMC), Melaka All participants are required to submit a participation form before 31st March 2011. The registration fee is required to be paid before 30th April 2011. PARTICIPANT DETAILS I / We will attend the event as a ……………….. PARTICIPANT

DELEGATE

Institution Person in Charge Name Position in Institution Institution Address Postcode

City

State

Fax

Telephone / Mobile

E-mail

REGISTRATION FEE FOR PARTICIPANT Number of participants (1 team = 14 person = 1 car)

Driver’s National Competition License Team’s Entrance License Entry Fee

Fees RM 200.00 per driver X no. of driver RM 150.00 1 per institution RM 600.00 per team X no. of team

Total Amount (RM)

150.00

Detail of account: Bank draft/Cheque made payable to: PENGARAH IKM JASIN, MELAKA For Electronic Fund Transfer (EFT): Beneficiary Name: Institut Kemahiran Mara Jasin, Melaka Bank Name: CIMB BANK BERHAD Account No: AKAUN HASIL INSTITUT KEMAHIRAN MARA JASIN 0407 – 0008528 – 05 – 2

TOTAL AMOUNT TO PAY 1. Each institution can send up to a maximum of two team / car for this event. 2. Email to [email protected] if your institution pay the fees through electronic fund transfer for our record. 3. The registration fee includes mineral water, breakfast & lunch for 3 days (10th - 12th June 2011) and 10 liter of fuel. Please fax your participation form to us to: En. Md. Shafiee bin Mohd Noh (Pendaftaran & Penyertaan IPMARace 2011, IKM Jasin, Melaka) Tel: 06 - 529 1561 Fax: 06 - 529 2561 Email: [email protected]