Royal Enfield Tour of Bhutan 2013

For registration you will need to send the following to us:

Registration form

Indemnity bond

Medical history by self

Medical certificate by doctor

Two stamp size photographs (with name of participant written behind)

Demand draft of INR 25,000/- drawn in the name of “Eicher Motors Ltd.” payable at Chennai (with name of participant written behind)

Copy of your driving license

Copy of vehicle registration and insurance certificate valid for the duration of the trip

Copy of medical insurance policy valid for the duration of the trip

All forms should be complete and signed. Attach them together and mail to:

Royal Enfield Tour of Bhutan2013

C/O Mr. Adarsh Saxena
Marketing Division

Royal Enfield (A unit of Eicher Motors Ltd)

Thiruvottiyur High Road

Thiruvottiyur

Chennai, Tamil Nadu.

Pin: 600 019

For any further queries and information you may contact Adarsh Saxena on +91- 9445193687 or send a mail to

· Eligibility Criterion: Please read the eligibility criterion listed out on the website. Participation in Tour of Bhutan 2013 will be subject to physical fitness evaluation, riding gear inspection & motorcycle scrutiny that will be held in Ahmedabad before the start of the ride.

· Rules & Regulations: Please read the rules & regulations listed out on the website. Any conduct found compromising your individual or group safety will not be tolerated.

Registration Form

(To be completed by the participant in CAPITAL letters)

Personal Details

Name ______
Address ______
______
State ______City ______Pin ______
E mail id ______

Phone (Res) ______(Off) ______(Mob) ______

Emergency contact person (blood relative) ______
Emergency contact address ______
______
State ______City ______Pin ______
Phone (Res) ______(Off) ______(Mob) ______
T shirt size 40 42 44 46

Marital status Single Married
Driving license no ______
Profession ______
Education ______

My Royal Enfield Motorcycle

Model name ______Year of manufacture______Total km ______
Registration number______Engine/Chassis number ______
Modifications done ______
Customization ______
Average distance covered per Month ______
Clubs I am a member of ______

I have read and accept the Eligibility Criteria and understand that my participation will be subject to physical fitness test, riding gear inspection & motorcycle scrutiny.

Signature ______Date ______

INDEMNITY BOND

TO WHOM SO EVER IT MAY CONCERN

This is to declare that I ______
son/daughter of ______
address ______
______
______
take sole and absolute responsibility for the well being of myself & material/ property/ equipment that I am carrying with me.

Under no circumstances will I or any person/ company hold Royal Enfield or any person/ organization connected/ associated with organizing/ assisting in the Royal Enfield Tour of Bhutan 2013, responsible for any sort of injury/ sickness/ damage/ loss/ accident/ delay or irregularity during or arising out of this trip.

I will abide by all rules and regulations laid down by the organizers, failing which I authorize the organizers to immobilize my vehicle and leave without me.

I declare that I am voluntarily participating in this trip and am fully aware of all the associated risks to my life and material belongings.

I have attained the age of maturity and am competent to give this declaration.

Signature ______

Date ______Place ______

Medical history by self

(To be completed by the participant in CAPITAL letters)

Participant’s Name

Sex / Date of Birth
No / Yes / Details
Loss of consciousness for any reason, dizziness or headache
Eye problems (except glasses)
Asthma
Allergy to medicines or drugs
Diabetes
Heart problem
Blood pressure disorder
Stomach problems (ulcer, etc.)
Uro-genital problems
Epilepsy or convulsions
Mental or nervous disorders
Problems with arms or legs including muscle cramp or joint stiffness
Blood disorder with tendency to bleeding
Operations
Do you take medicine or drugs regularly?
Have you been rejected or accepted at increased premium for life insurance on medical grounds?

a. I have not been banned, on medical grounds, from taking part in any sport.

b. I do not take drugs and do not abuse alcohol.

c. In case of an injury I give permission to the Medical Staff to release any relevant information to the ride coordinators and Royal Enfield.

d. I declare that the information that I have given is true.

e. I agree to the information on the Medical Examination form being sent to the Doctors deployed by Royal Enfield.

Note: The act of producing this certificate at the Tour of Bhutan 2013 is deemed to be a formal declaration by its holder that he/ she, since its issue, has suffered no illness or injury which might be liable to affect its validity.

Signature of the applicant ______

Medical certificate by doctor

(To be completed by the doctor in CAPITAL letters)

Participant’s Name

Blood Group / Height / Weight
Normal / Abnormal / Details
Cardio-vascular system
Blood Pressure (mention reading)
Pulse
Respiratory system

Nervous system

Central
Peripheral

Ear, nose & throat, in particular vestibule cochlear apparatus

Right
Left

Locomotor System

Arm – Right
Arm – Left
Leg – Right
Leg – Left
Spine
Abdomen (Hernia)

Urine

Albumen
Glucose
Eyes – Distant Vision /

Without correction

/ With correction
Right
Left

I, the undersigned certify that in respect of the Royal Enfield Tour of Bhutan 2013, this person

Is fit to attempt the physical fitness test (for evaluation of physical fitness) and take part

Is not fit to take part

Doctor’s Name: ______

Date: ______Signature & Seal