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: ______________