Full Name (Include Middle Initial) :    

     Your Chosen Biker Name :      

    Street Address:      City:    State:   Zip code:

     Home phone:     Cell phone:     Business phone:

     Age:         e-Mail address:

     Emergency Contact Name:      Emergency Contact Phone:

     Please give a brief history of yourself (including military service, current employment and membership in any other    motorcycle clubs.

     Are you legally licensed to operate a motorcycle:  Yes       No

     Do you currently own a motorcycle:   Yes      No

     If yes, please provide the following info below:

     Make:      Model:       Year:      Cc:

     Years riding experience:

     Please explain why you are interested in becoming a member of the Clarksville, Tn. Chapter of the Buffalo Soldiers Motorcycle Club?