Prime Mining City to Surf Registration

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To Register your team in the Prime Mining City to Surf for Activ 2010, complete the Registration form below. All Team registrations are conducted by the Team Organiser and confirmed via email upon completion of this form. By successfully completing the form below, the Team Organiser and Host Company accepts the Terms and Conditions.

Name of Team:

Name of Company:

Name of Team Organiser:

Contact Phone:

Email Address:

Site Name/Location:

Postal Address:

The following section
of this form refers to
the entity to be invoiced

Name to appear on Invoice:

Contact Person for Invoicing:

Email Address to Invoice:

Contact Phone of Accounts Person:

Please Enter Code:

Agree to Terms?: