Registration

Please register for the cyclist advanced skill level only

Title (required)

Your Name (required)

Your Email (required)

No. KTP / Pasport /Foreigner with Passport Copy(required)

Telephone(required)

Address

City

Zip Code

Nationality

Sex (required)

Date of birth (D/M/Y) (required)

Room (required)

Jersey Size (required)

Own Insurance by (not required)

Insurance No (not required)

Leave Us A Note

Attention:
Please read carefully Bintan Audax Rule before submit at  http://pedaltrip.com/event-info/rule-regulation/
I have read the rules of Bintan Audax  and accept them without reservation.
Registration and Payment will be closed on  …………

PAYMENT of ENTRY – Fee including : … nights +  breakfast  / …. times lunch / 2 times dinner/ airport transfer , free refreshments during cycling and 1 pc jersey.

Transfer PAYPAL
Paypal Account : balicycling@yahoo.co.uk
for paypal USD ……. (Share Room)  and USD ……. (Single Room) (*tax included)

or

Transfer Bank Indonesia
Rp. …….. (twin room) and Rp. …….. ( single room)

Bank Central Asia (KCU Kuta) Jl. Raya Kuta No. 55X Denpasar Bali 80361, Indonesia
Name : I Wayan Kertayasa
No. Rekening/Account number : 1 4 6 1 7 0 1 5 7 0
Swift Code : CENAIDJA

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