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FORMULIR PENDAFTARAN OFFLINE

NO FORMULIR ; _____________________
TANGGAL ; _____________________

NAMA ;
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EMAIL ;
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NO IDENTITAS ; KTP | SIM | PASSPORT
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NO. BPJS ;
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NO. HP ; _______________________________________

KATEGORI LOMBA ; 1. INDIVIDUAL OBSTACLE RUN


2. MILITARY TEAM OBSTACLE RUN. TEAM NAME:
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3. CIVIL TEAM OBSTACLE RUN. TEAM NAME:
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4. FUN RUN 5K
5. FUN RUN 10K
6. KID DASH
UKURAN JERSEY ; S | M | L | XL
JENIS KELAMIN ; PRIA | WANITA
TEMPAT TGL LAHIR ;
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ALAMAT ;
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GOLONGAN DARAH ; A | B | AB | O
RHESUS ; +|-

NAMA KONTAK DARURAT ;


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NO TELP KONTAK DARURAT ; _____________________

KUITANSI PENDAFTARAN OFFLINE


NO FORMULIR ; _____________________
TERIMA DARI ;

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UANG SEBANYAK ; (_______________________________)

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GUNA PEMBAYARAN ; PENDAFTARAN ADISUTJIPTO URBAN OBSTACLE RUN


2019
KATEGORI _________________________________________

YOGYAKARTA____________________________

1
SEPTEMBER 2019
LANUD ADISUTJIPTO YOGYAKARTA

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