Registration

Please register for the cyclist advanced skill level only

Attention:
Please read carefully Bintan Audax Rule before submit at  http://bintanaudax.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  20 November 2016

PAYMENT of ENTRY

Entry fee only Bintan Audax 200 km

Rp. 1.700.000 including:

  1. Lunch sea food  1 time;
  2. Dinner Nasi Padang 1 Time,
  3. Refreshments during the cycling time,
  4. Jersey 1 pc.
  5. Medal
  6. Support car

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

 

14054151_1340781439283490_838794902556500941_n1

jersey-bali-audax

 

 

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)

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