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Nassau County Fire RidersMotorcycle ClubEst. 1989 |
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Nassau County Fire RidersMotorcycle ClubEst. 1989 |
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LAST NAME _______________ FIRST NAME __________________ MI ______ DATE OF BIRTH (MONTH/YEAR) _________________________ HOME ADDRESS _______________________________________________________ TOWN ________________________________ STATE _______ ZIP+4 ____________ MAIL ADDRESS (If different) ________________________________________________ TOWN ________________________________ STATE _______ ZIP+4 ____________ HOME PHONE ________________ SIGNIFICANT OTHER'S NAME _____________ FIRE DEPT. ____________________________ CIRLCE ONE: ACTIVE OR EXEMPT HIGHEST RANK __________________ DO YOU OWN A MOTORCYCLE? YES NO MAKE _____________________ MODEL _____________________ YEAR ______ |
ASSOCIATE MEMBERS CHECK HERE { } |
The Nassau County Fire Riders Inc. and it's officers or members shall not be liable or responsible for
damage to property or injury to persons during chapter activities. All Nassau County Fire Riders Inc.
members participate in chpater activities at their own risk.
SIGNATURE _______________________________ DATE ______________
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INCUMBENT PRESIDENT___________________________________________ FD MEMBERSHIP CONFIRMED BY: _________ MC MEMBERSHIP CONFIRMED BY: _______ TYPE OF MEMBERSHIP CIRCLE ONE: FULL (Limited to F.D. members only) ASSOCIATE RECOMMEND TO ACCEPT : YES _________ NO __________ DATE ACCEPTED ___________ |
