REGISTRATION FORM

13TH UPSI INTERNATIONAL INDOOR HOCKEY

CHAMPIONSHIP 2019
SETITIS HORNET
TEAM NAME : ………………………………………………………………………
MOHD SHARIL BIN HARUN
MANAGER NAME : ………………………………………………………………………
MUSAIFUL HAZIM BIN ISMAIL
COACH NAME : ………………………………………………………………………
SEKOLAH KEBANGSAAN TITI SERONG
ADDRESS : ………………………………………………………………………
012-4688910 / tengas_12@yahoo.com
PHONE NUM / EMAIL ADDRESS: ……………………….……………………………
CATEGORY : VETERAN (M) ( )
: UNI / OPEN (M) ( ) UNI / OPEN (F) ( )
: UNDER 16 (M) ( ) UNDER 16 (F) ( )
: UNDER 12 (M) ( / ) UNDER 12 (F) ( )
NO PLAYER NAME PASPORT NUMBER

1
AHMAD AMIRUL AKMAL BIN MAT NAIM (GK) 070202-08-0365
2
MUHAMMAD DANIEL HAIQAL BIN MOHD SHARIZAL 070516-08-0069
3
MOHAMAD SHAHRUL AMIN BIN MOHD SUHAIMI 070831-08-0173
4
ADAM MIKHAIL BIN ROSLI (C) 070702-08-0657
5
MUHAMMAD ADAM UZAIR BIN SALLEH 070803-08-0219
6
MUHAMMAD ADAM FAKHRULLAH BIN KASPUL ANWAR 070727-08-0261
7
RAHUUL FAZRIEN BIN MUHAMMAD NAZRIEN 070403-08-0409
8
MOHD FAREEZ BIN ABDUL RAZAK 070507-08-0761

*please photocopy passport

There are TWO ways of payment ( BANK ISLAM ):

1. ePayment@UPSI (https://epayment.upsi.edu.my/onlinesport/)
2. Cheque (BENDAHARI UPSI (ACCOUNT NO: 08068010003264)
13TH UPSI INTERNATIONAL INDOOR HOCKEY
CHAMPIONSHIP 2019

TEAM DECLARATION FORM

NAME
MOHD SHARIL BIN HARUN

NO TEL
012-4688910

TEAM
SETITIS HORNET

MOHD SHARIL BIN HARUN

I _________________________________________ hereby agree that I will not take any legal

action against the organizers of 13TH UPSI INTERNATIONAL INDOOR HOCKEY

CHAMPIONSHIP 2019 for any accident, injuries and death that might occur during and

after the sport events.

Yours sincerely, Witness,

__________________________ __________________________
Name : MOHD SHARIL BIN HARUN Name : MUSAIFUL HAZIM BIN ISMAIL

Date : 24/10/2019 Date : 24/10/2019