The Kazbegi marathon Sep 8 2012

Registration Form

The Kazbegi marathon Sep 8 2012

- Dear runner thank you for your application, please complete The required details in capital letters

Surname SHCHEPACHKOV first name ALEXANDER

Street & house number: ROZHDESTVENSKAIA str., 4-47 sex: M

Date of birth 09/10/1984

City: ZAVOLZHIE, ROZHDESTVENSKAIA str., 4-47

Zip/postal code: 606523

State- province: NIZHEGORODSKAIA OBLAST Country: RUSSIA

Telephone: [phone] Nationality: RUSSIAN

E-mail address: [e-mail]

I will participate in the following race

Long Marathon - 42Km

Half marathon - 21 Km

8 km road race

Size T-shirt

M

Surname/first name of person to contact in case of severe illness ALEKSANDRA BELIAKOVA

E-mail address of person to contact in case of severe illness [e-mail]

Phone number and cellular number of the person to contact in case of severe Illness: [phone], [phone]

Date 30/07/2012 signature

Дата добавления: 2015-11-04