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REGISTRATION FORM 2012

Please complete this registration.
Your registration will only be considered complete once the fees of both participants have been received and all necessary information has been supplied on the application form.

Team Information

* Team Name :

*Package:

*Category:

Riders Information

Rider 1 (Team Leader)

Rider 2

* Last Name :

Last Name :

* First Name :

First Name ::

* Date of Birth :

Date of Birth :

* Street Address :

Street Address :

* City :

City :

* Country :

* Zip Code :

* Home Phone :

Home Phone :

* Office Phone :

Office Phone :

* Mobile Phone :

Mobile Phone :

* Fax Number :

Fax Number :

* Email:

Email :

* Nacionality:

* Male/Female:

* T-Shirt Size:

* T-Shirt Size :

I agree to indemnify the exclusion of liability by the organizer, management and sponsors for damage and injuries that a participant may suffer and that I will not enforce a claim against the aforementioned by legal action. I have read and accept all the "Terms and Conditions" as well as "The Rules and Penalties" that govern the race event El Reto del Quetzal (refer to www.elretodelquetzal.com for details). I Authorize the use of video and photographic images from the race event. Once a team registered the registration fee is non refundable and by signing this registration I affirm and accept that my participation in the race event will be strictly at my own risk. This registration constitutes a binding contract.

agree

Registration Options

Rider 1 (Team Leader)

Rider 2

Item	Cost	Size	Qtty
Offical Jersey:	$45.00
Offical T-Shirt	$10.00
Offical Cap	$10.00
Offical polo:	$35.00
Mechanic Service :	$75.00
Massage one day:	$25.00
Massage for three days:	$65.00
Companion:	$500.00
Other
Transfer reu-guate $20

Item	Cost	Size	Qtty
Offical Jersey:	$45.00
Offical T-shirt	$10.00
Offical Cap	$10.00
Offical polo:	$35.00
Mechanic Service:	$75.00
Massage one Day:	$25.00
Massage for three days:	$65.00
Companion:	$500.00
Other
Transfer reu-guate $20

PAYMENT

REGISTRATION INFORMATION

REQUIRED FIELDS

* Wire transfer # :

*Transfer Date :

Registration Payment

Intermediary Bank:
Bank: BAC FLORIDA BANK
Address: 169 Miracle R-10 Coral Gables Florida
Swift code: BFLBUS3M
ABA: 067 009 044

Beneficiary Bank:
Name: Banco de América Central S.A
Address: 7a ave 6-26 zona 9 Guatemala
Account Number: 030 861600

Final Beneficiary
Name: Adrenaline
Address: 17 calle 5-36 zona 1 Guatemala ciudad
Account Number: 90-015755-3
Bank Name: BAC (Banco de America Central)

Additional Bank info

Bank of America
Name: Bank Of America
Address: New York USA
Swift Code: BOFAUS3N
ABA: 026009593

Beneficiary Bank:
Name: Banco de América Central S.A
Address: 7a ave 6-26 zona 9 Guatemala
Account number: 1901335079

Final Beneficiary:
Account Name: Adrenaline
Address: 17 calle 5-36 zona 1 Guatemala ciudad
Account Number: 90-015755-3

Updated: 12/13/2011

For more information please e-mail us at info@elretodelquetzal.com

For more information please e-mail us at info@elretodelquetzal.com

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