Membership Application

Name:________________________________________    Date of Birth:____________________

Co-Rider Name:_______________________________    Date of Birth:____________________

                                                                                 Anniversary:_________________________________

Address:_____________________________________    City:_____________________________

County:______________________________________    Zip:______________________________

Phone:____________________    Email:_______________________________________________

Motorcycle Information:

Year:________ Make:______________ Model:_________________ Color:___________________

Honda Riders Club of America Membership #:___________________________ Exp:_________
(Note: Honda riders club membership is not required.

Signature:______________________________________________________ Date:_____________

Dues are due yearly New: _____ ($20.00 per person) - Renewal: _____ ($15.00 per person)

Please make checks payable to "Northeast Pleasure Riders"
Then Mail to 412 Gilbert St., Scranton, PA 18508
© 2002, 2006, 2007, 2008 by NEPR