Application

First Name

Middle Name

Last Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Cell

Email Address

Date of Birth

Month

Day

Year

Place of Birth

Qualifications:

Are you a citizen of the United States?YesNo

Do you support the Constitution of the United States of America?YesNo

Are you or were you a member of the U.S. MilitaryYesNo

Are you or were you a member of Law Enforcement, Fire Fighter, or EMS?YesNo

Do you have a valid driver's license?YesNo

Do you have a motorcycle endorsement?YesNo

If no, do you plan to get one?YesNo

If legally permitted, do you own a firearm?YesNo

Do you own a motorcycle?YesNo

If yes, Year:

Make:

Model:

Emergency Contact:

Name:

Cell:

References (One must be an active member):

Name

Relationship:

Phone

Name

Relationship:

Phone

LMRC Preferences and By Laws:

Chapter Applied For:Thomas JeffersonJames MadisonM. K. Goddard (Ladies ONLY)Thomas Lynch Jr.Other...

Preferred Road Name (If Applicable):

I hereby certify that I have read this Waiver, Release and Assignment of Claims in its entirety. My acceptance of a back patch indicates that I fully understand it and agree to its contents.YesNo

Please do not fill in this field.

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