::: Shiftn Steel Sport Riderz Application :::

Today's Date:		Nick Name:
Name:*		Make/Model of Motorcycle:
Address:*		Number Years Riding:
City:*		Insurance Company:
State:*		Policy Number:
Zip:*		Chapter of Interest:*
Telephone:*		Emergency Information:* (Include a contacts info and your blood type if known)
Cell Phone:		Are you taking medication?	Yes No
Date of Birth (mm/dd/yyyy):		If Yes, Please Explain:
Email Address:*		Are you a member of any other clubs?	Yes No
		List other clubs:
		Tell us something about yourself:

	Electronic Signature Acknowledgement: * I, (the undersigned), will receive a copy of the Shiftn Steel Sport Riderz Shift Patterns (By-Laws), will accept all the Shift Patterns set forth by the organization, and will promise to uphold the image and support Shiftn Steel Sport Riderz to the fullest.
Thank you for taking time to fill out this application for membership to the Shiftn Steel Sport Riderz motorcycle organization. We look forward to having you in the family. Upon submitting your application for membership to Shiftn Steel Sport Riderz the President and/or the Vice President will contact you within 24 hours.

MEMBERSHIP APPLICATION