* grey background

indicates that an entry is essential

Title

Mr Mrs Ms Miss Dr Sir

First name

*

Surname

*

Age

*

Address, line 1

*

Address, town

*

Postcode

*

Evening tel no

*

Daytime tel no

*

Mobile tel no

(Please supply at least one land-line tel number)

Fax no

e-mail address

*

e-mail address
(repeat please)

*

Occupation

*

Employer

*

Do you work for a employer that offers "matched giving"?

  Yes
* No
  Don't know

TICK if your employer is likely to help in other ways

Donation?

Promotion (eg noticeboard space, newsletter)?

Other?

For Vest/T-shirt ordering purposes SIZE S / M / L / XL / XXL 

Please fill in to get your FREE running vest

S M L XL XXL

Running experience:

Years

Miles per week now

Member of club? (Name)

Number of Half Marathons completed

Personal best in hrs:mins
( eg 3:45)

Personal best; what year?

Other personal bests

Have you taken part in any runs before? (if no, please leave blank)

Number of times

  Most recent year

Have you raised sponsorship money for charity before? Please give details:

How much sponsorship money do you think you could raise?

Please list the likely sources of sponsorship - eg work colleagues,
clients, clubs, schools etc

Do you have any friends who are planning/would like to run for apec?
Please give details - tel no or address - and state if they have their
own place.

Any other information relevant to your participation?
(eg particular reasons for interest in the charity)

This information will not be disclosed to any third party, though we may consult you about featuring you in a press release about your participation if you agree by ticking here:

Where did you hear about Action on Pre-eclampsia?

APEC Mailing
Previously run for Action on Pre-eclampsia

Great Run Magazine

Word-of-mouth or other recommendations

Publicity (eg poster)

Other (please give details below)