PRIDE GUARDIANS MOTORCYCLE CLUB
MEMBERSHIP APPLICATION
PO BOX 714  LOUISA, VA 23093
540-894-7075

NAME: ________________________________________________________________________________________

ADDRESS: _____________________________________________________________________________________	

CITY:	_____________________________	STATE: ________ZIP:  ___________

PHONE:  Home _____________________ Cell ___________________ Work (optional)________________			
DOB: _________________________         

EMAIL ADDRESS:  ____________________________________@_________________________

MOTORCYCLE(S):  Color/ Year/ Make/ Model:

Motorcycle License:  (circle one) YES      NO

Insurance Certification:  By signing this application, I certify that this motorcycle is insured by a liability policy issued through an insurance company licensed to do business in Virginia, and it will remain insured while registered.

                               Membership Fees:  $50                               Annual Dues:  $20

Applicants Signature: ____________________________________________ Date: ___________________

FOR OFFICE USE ONLY:  

Amount Due: _______ Amount Paid: _______ Paid To: _____________ Date Paid: ________