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Emerald
Coast
Riders A Retreads Motorcycle Club Membership Application |
New _______ Renewal _______ Date ______________________
(Please type or print. Name, address, and date of birth must be completed
before a membership card is issued. You and/or your spouse must be over 40
to be a full member. 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:
_____________________
AMA Number: (if member):_________________ Expiration Date:
______________________
Other MC Affiliations (or civic
organizations):________________________________________
Occupation(s):
_______________________________________________________________
Hobbies:____________________________________________________________________
Make of Motorcycle(s):_________________________________________________________
Referred
by:_________________________________________________________________
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Please return application
to:
David Stemen, Membership
11 Cousineau Road
Pensacola, FL 32507
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Donation: $ _____________
$20.00 per Couple per year or $15.00 Single per year
Make check or money order payable to: Sunshine Region Retreads
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IMPORTANT: This must be
signed by all applicants.
I
understand that the Retreads cannot assume responsibility for any aspect
of my safety. I understand that my participation in any Retreads activity
is strictly voluntary and further, I release and hold harmless the
Retreads or any Retreads member from any loss to my person or property.
Signature:____________________________________ Spouse:
______________________________________
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Director Use: Card(s) issued:____________ Card(s) Mailed:
______________