Membership Application

Name:________________________________________    Date of Birth:____________________

Co-Rider Name:_______________________________    Date of Birth:____________________

                                                                                 Anniversary:_________________________________

Address:_____________________________________    City:_____________________________

County:______________________________________    Zip:______________________________

Phone:____________________    Email:_______________________________________________
(Is it OK if we give your Phone # and E-Mail Address to other Members?)yes__ no__

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: _____ ($15.00 per person) - Renewal: _____ ($12.00 per person) in Jan. of each year

Please make checks payable to "Northeast Pleasure Riders"
Then Mail to 412 Gilbert St., Scranton, PA 18508
© 2002, 2006, 2007, 2008, 2009 by NEPR