Document 351437

NEW GAMES INCLUSION FORM: Fee 11000/-INR (3rd Dr. B.R.
.R. Ambedkar National Games-2015)
Game
FEDERATION/ORG. NAME_____________________
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LEGAL STATUS_______________________________________________
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ADDRESS______________________________________________
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CITY/DISTRICT__________________________
______________STATE_______________________________________________
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PRESIDENT NAME________________________
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DATE OF BIRTH________________________________AGE________SEX_______________________________
E-MAIL__________________________________PHONE/MOBILE_____________________________________
MAIL__________________________________PHONE/MOBILE_____________________________________
SECRETARY NAME___________________________________________________________________________
NAME___________________________________________________________________________
DATE OF BIRTH________________________________AGE________SEX_____________
BIRTH___________________
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E-MAIL_____________________________
_____________________________PHONE/MOBILE_______________________
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SPORTS ______________________________
__________EVENTS____________________________________________
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Please Enclose Rule Book & State Members List
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE, FURTHER, I DO HEREBY, FOR MYSELF, MY HEIRS, EXECUTORS AND
ADMINISTRATORS, WAIVE RELEASE AND FOREVER DISCHARGE ANY AND ALL RIGHTS AND CLAIMS FOR DAMAGES WHICH I MAY HAVE OR WHICH
MAY HEREAFTER
R ACCRUE TO ME AGAINST THE DR. B.R. AMBEDKAR SPORTS FOUNDATION OR THEIR RESPECTIVE OFFICERS, AGENTS,
REPRESENTATIVES, SUCCESSORS AND/OR ASSIGNS, FOR ANY AND ALL DAMAGES WHICH MAY BE SUSTAINED AND SUFFERED BY ME IN
CONNECTION WITH MY ASSOCIATION WITH OR ENT
ENTRY
RY IN THE SPORTS ACTIVITIES ASSOCIATED WITH DBRASF. IN ADDITION, BY MY SIGNATURE, I
CERTIFY I UNDERSTAND THAT SUBMISSION OF A COMPLETED APPLICATION AND THE APPROPRIATE.
SIGNATURE____________________
_____________ NAME_______________________________________
NAME_______________________________________________________
WITH ORGANIZATION SEAL
DATE_________________________PLACE_________
__________PLACE__________________________________________
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FOR OFFICE USE ONLY:MEMBERSHIP NO___________________________________________________________________________
NO___________________________________________________________________________
AUTHORIZED SIGNATURE______________________________DATE___________________________________
Proud Member of Tafisa, Recognized by International Olympic Committee & World Health Organization
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