Emzor Pharmaceutical Corporate Website: Human Pharmaceuticals and Consumer Health Care, Animal Health Business

Emzor Monthly Wellness Race

Enrolment Form

Participants are requested to complete this Form In utmost sincerity to help the medical team determine their fitness levels to participate in this event. All information shall be treated in strict confidence.

PARTA - Bio-data & Personal Information (To be filled by Participant)

Name*: First Last

Sex: * Male Female

Date of Birth: * /DD /MM YYYY

Marital Status: *

Age:

Residential Address: *

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Mobile Phone Number: *

Email: *

Nationality:

Next of kin: * First Last

Place of Work / Address:

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Person to be contacted in the event of an emergency: * First Last

Phone No of Person to be contacted in the event of an emergency

PART D - DECLARATION BY THE PARTICIPANT

I hereby pledge that all the information I have supplied is true and correct and hereby DECLAREthat I am in good health to participate in this program. I also hereby waive, exempt & release Emzor Pharmaceuticals Industries Limited or its subsidiaries or affiliates from any liability that may arise by virtue of my participation in this program. My unqualified acceptance & agreement to the rules & regulation/terms & condition of participation is evidenced by my completion and submission of this Form to the program organizers.

Security Code

Emzor Monthly Wellness Race

Enrolment Form

PARTA - Bio-data & Personal Information (To be filled by Participant)

PARTB - Social/Family History (To be filled by Participant)

Part C- Medical History (Should be completed under the guidance of medical personnel)

PART D - DECLARATION BY THE PARTICIPANT