HI-ROLLERS MOTORCYCLE CLUB FULL MEMBERSHIP

**PLEASE PRINT**

DATE:      ________________

NAME:      ___________________________________________________________

ADDRESS:   ___________________________________________________________

CITY:      ________________________  STATE:__________ ZIP:____________

PHONE:     (______)_________________      BIRTH DATE: ________________

A.M.A. #:  _______________________   EXPIRATION DATE: ________________

E-MAIL:    ___________________________________________________________

Sponsors Names (2):_________________________ , _______________________
(Sponsors must be a Full Member in good standing for the past twelve (12) months)

Applicant Please Sign:_________________________________________________________
By signing this form I agree that upon my leaving the club or becoming a member not in good standing I shall return my Full Member Patch to the club for reimbursement minus wear to the patch.

MOTORCYCLE INFORMATION
MAKE:________________MODEL:_______________YEAR:___________

FULL MEMBER FEES:

INITIATION: $10.00 _________ (ONE TIME ONLY)

PATCH:      $25.00 _________ (PER-PATCH)

CLUB DUES:  $25.00 _________ (PER-YEAR)

    TOTAL:  $60.00 _________