Some Bike Club M/C

INFORMATION SHEET

Chapter:

Type: Regular Member / Prospect / Special Member / Member at Large (circle one)

NAME: ____________________________________________________ Nick: ___________________

ADDRESS: ______________________________________________________ Apt #: _____________

CITY: _____________________________________ State: ______________ Zip: _________________

PHONE: HM: (______)_________________________ Cell: (______)___________________________

E-Mail _____________________________________________________________________________

Birth Date: (MM/DD/YY): ____/____/____ Gender: Male / Female

Sobriety Date: (MM/DD/YY): ____/____/____ or Special : ___________________________________

Motorcycle: Make:_____________________ Model: ____________________ Yr:____ Size:_____ cc

Valid Motorcycle Operators License: No. _____________________________ State: _______________

License Plate: ____________________________________ State: ______________________________

Insurance Company: __________________________________________________________________

Policy Number: ______________________________________________________________________

Prospect’s Sponsors: __________________________________________________________________

Start Date: (MM/DD/YY): ____/____/____

Prior M/C Affiliation (Optional) __________________________________________________________

Notes: _____________________________________________________________________________

__________________________________________________________________________________

Special Interests: _____________________________________________________________________

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Send 1 copy to Executive Board (Check Payable to: Janet & Leon Graham) Membership $ 100.00