RETREADS® MOTORCYCLE CLUB INTERNATIONAL, INC.
AMA CHARTER 3233
APPLICATION FOR MEMBERSHIP
2009 New
_____
2009 Renewal _____ Date ______________________
(Please type or print. Name, address and date of birth must be filled in, 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 December. )
Name ______________________________________
Spouse _____________________________________
Address_____________________________________
City________________________________________
State____________Zip Code_______
Telephone (
)__________________________
E-mail _____________________________________
Your Birthday __________________________
Spouse Birthday__________________________
AMA Number (if member)_____________________
Expiration Date(s) ___________________
Other M.C. Affiliations (or civic organizations) [VFW, American Legion, Elks,
Moose, ABATE MRF, AIM/NCOM, etc. include Post Number or location]:
_________________________________________________
Occupation(s) _________________________________________________
Hobbies___________________________________________
Make(s) of Motorcycle(s)_________________________________________________
Referred by _________________________________
Or Number of years in the Retreads® ______
*************************************************
Please Return Application to:
Jim & Sue Everhart XL+
445 N. County Home Rd.
Lexington NC 27292
Phone: (336) 249-7867
Fax: (336) 236-1405
E-mail:
jseverhart@triad.rr.com
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CHOOSE ONE MEMBERSHIP OPTION BELOW - MAIL OR E-MAIL NEWSLETTER
MEMBERSHIP
Mail Newsletter Membership Donation: $ ____________
$20.00/Couple or $15.00/Single per Year
E-mail Newsletter Membership Donation: $ ____________ $15.00/Couple
or $10.00/Single per Year
Out
of Region Member Newsletter Only ($10.00): $ _______
Free 3-inch decal with MEMBERSHIP Yes ___ No ____
Make Check or Money Order Payable to: MID-SOUTH RETREADS
******************************************************
THIS APPLICATION FOR MEMBERSHIP MUST
BE SIGNED BY ALL MEMBERS:
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__________________________________
************************************************************
For Office use only:
CARD ISSUED: __________
CARD ISSUED: __________
CARD (S) MAILED ___________
Date Forwarded to International __________
Date Forwarded to Mid-South Regional __________
