APPLICATION FORM

EUROPEAN MUAYTHAI CHAMPIONSHIP

OCTOBER 14-18 2015

Please fill in clearly in capital letters:

Id. Card No.:

* Indicates required field

INSERT RECENT
PICTURE

1. Name of the organization and country*

3.5cm X 4.5cm
2. Full name shown in passport *
First name*

Surname/Family Name *

3. Passport number *

4. Gender *
Female

Male

Expire date (DD/MM/YYYY) *

5. Position within the National Federation

Status: *
Official

6. Date of birth *
DD
MM
YYYY

7. Place of Birth *

8. Nationality *

9. Secretary General signature and stamp of the organization *

Date:

APLICANT DECLRATATION *

I do understand the risk of entering into the Muaythai competition. I do participate at my own free will.
I will take the full responsibility in case of any injury or accident. I declare not to blame or take any
legal charge on promoters, officials or the World Thai Boxing Federation or any third party involved in
organizing this Championship by signing this application form.

Applicant Signature:
Date:
Please send the application form before 10th September 2015, to the address below:
Public Relation: asociaacionandaluzamuaythai@gmail.com
Office W.T.B.F: ram.muay@hotmail.com