Emerald Coast Riders

Membership Application

New _______   Renewal _______                                         Date ______________________

(Please type or print.  Name, address, and date of birth must be completed before a membership card is issued.  Memberships are valid from January 1st to
December 31st.  Please renew in October through December.)

Name: ________________________________  Spouse: _____________________________
Address: ______________________________   Phone:  _____________________________
City, State, Zip: ______________________________________________________________
Email address:_______________________________________________________________
Applicant’s Birthdate: _____________________  Spouse Birthdate: _____________________
Other MC Affiliations (or civic organizations):________________________________________
Occupation(s): _______________________________________________________________
Hobbies:____________________________________________________________________
Make of Motorcycle(s):_________________________________________________________
Referred by:_________________________________________________________________

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Please return application to:
David Cook, Membership
3516 Fawnwood Drive
Pace, FL 32571
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Donation:  $ _____________
$20.00 per Couple per year or $15.00 Single per year
Make check or money order payable to:  Emerald Coast Riders
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IMPORTANT:  This must be signed by all applicants.
I understand that the Emerald Coast Riders cannot assume responsibility for any aspect of my safety.  I understand that my participation in any Emerald Coast Riders activity is strictly voluntary and further, I release and hold harmless the  Emerald Coast Riders or any  Emerald Coast Riders member from any loss to my person or property.


Signature:____________________________________  Spouse: ______________________________________

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Director Use: 
Card(s) issued:____________    Card(s) Mailed: ______________