NEW GAMES INCLUSION FORM: Fee 11000/-INR (3rd Dr. B.R. .R. Ambedkar National Games-2015) Game FEDERATION/ORG. NAME_____________________ ______________________________________________________________ _______________________________________________ LEGAL STATUS_______________________________________________ __________________________________________ _____________ ______________________________ ADDRESS______________________________________________ ________________________________________ ____________________________________ ___________________ CITY/DISTRICT__________________________ ______________STATE_______________________________________________ _______________________________________________ PRESIDENT NAME________________________ ________________________________________________________ ____________________________ DATE OF BIRTH________________________________AGE________SEX_______________________________ E-MAIL__________________________________PHONE/MOBILE_____________________________________ MAIL__________________________________PHONE/MOBILE_____________________________________ SECRETARY NAME___________________________________________________________________________ NAME___________________________________________________________________________ DATE OF BIRTH________________________________AGE________SEX_____________ BIRTH___________________ ___________________________ E-MAIL_____________________________ _____________________________PHONE/MOBILE_______________________ ______________________________ SPORTS ______________________________ __________EVENTS____________________________________________ _____________________________ 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__________________________________________ ______________________________ FOR OFFICE USE ONLY:MEMBERSHIP NO___________________________________________________________________________ NO___________________________________________________________________________ AUTHORIZED SIGNATURE______________________________DATE___________________________________ Proud Member of Tafisa, Recognized by International Olympic Committee & World Health Organization