30 DAYS BIGGEST LOSER CHALLENGE
1ST APRIL - 30TH APRIL 2018
1. FULL NAME *
Your answer
2. I/C NO. / PASSPORT NO. *
Your answer
3. BIRTH DATE *
MM
/
DD
/
YYYY
4. E-MAIL ADDRESS *
Your answer
5. CONTACT NUMBER *
Your answer
6. PARTICIPATING CATEGORY
7. PARTNER NAME (FOR PARTNER CATEGORY ONLY)
Your answer
8. PRICING CATEGORY *
9. ANY MEDICAL HEALTH CONDITIONS? *
10. IF YES TO QUESTION 9, PLEASE LIST DOWN YOUR HEALTH CONDITION
Your answer
EMERGENCY CONTACT PERSON *
Your answer
EMERGENCY CONTACT NUMBER *
Your answer
PAYMENT METHOD

Payment can be made online. After registration, please make payment
to GILLIAN QHAL FITNESS (MAYBANK): 5142 7162 9266.

Once Payment is made, kindly email or Whats App payment receipt to: events.gqfitness@gmail.com OR 012-364 7678


Kindly Note that your place in the event will NOT BE CONFIRMED UNTIL PAYMENT HAS BEEN MADE.

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