Please be legible.

Name:
 		  
PO Box:
City: State: Zip:
 If
Applicable
Home Address:
City: State: Zip:
 Omit From
Membership
Listing
(   )
Home Phone: (   )
Work Phone: Optional
Fax Number: Optional
Other (list type & #): Optional
E-mail: Optional
Motorcycle(s):  
AMA #: BMWMOA #: BMWRA #:
 
Other Club(s), please list name(s):  
Please circle interests           (and list other interests)
Rallying Touring   Camping    Dinner Rides Breakfast Rides Sidecars  Racing   Vintage MCs
 

Associate Member Name:
 		  
Work Phone: Optional
Fax Number: Optional
Other (list type & #): Optional
E-mail: Optional
Motorcycle(s):  
AMA #: BMWMOA #: BMWRA #:
 
Other Club(s), please list name(s):  
Please circle interests           (and list other interests)
Rallying Touring   Camping    Dinner Rides Breakfast Rides Sidecars  Racing   Vintage MCs
 

Dues: Full Year (Oct.-Sept.): $25
Initiation Fee (first year ONLY to cover nametags): $5 for one member, $8 for two family members at same address

I hereby release the BUCKEYE BEEMERS from any and all liabilities and/or claims that may arise or that I may otherwise receive as a result of my membership or participation in the BUCKEYE BEEMERS or in any sponsored activity. As a member, I shall be liable for NO assessment, other fee or liability obligation except the initiation fee and annual dues.

Applicant's Signature and Date Associate Applicant's Signature and Date
Updated 09-29-2005

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