Registration Form Name: Home Address: Your email: Contact No: Date of Birth : 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 DD January February March April May June July August September October November December MM 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 YYYY Height Father's Name Mother's Name: Occupation: How can we contact you? Email Phone Did you read our RULES section? YES Why You Want to Join Miss India Malaysia? less than 30words Agree I have read and agree to follow the Rules and Regulations for the pageant I wish to enter. I also certify that the information presented in this form is correct. I understand that the PARAMOUNT ENTERTAINMENT reserves all rights pertaining to this contest and its decision is final.

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