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REGISTRATION FORM Milwaukee MENA Tour Date: Location:

21-26 April, 2013 USA

Please choose and tick one of the following: Rider 2 Riders Sharing a Room Rider & Pillion Sharing a Room

Cost/ Person $ 990 $ 1980 $ 990

First Rider Info:

Second Rider / Pillion Info: (Sharing a Room)

Last Name: __

Last Name: __

Nationality: __

Nationality: __

Date of Birth: __

Date of Birth: __

Email: __

Email: __

Personal Mobile #: __

Personal Mobile #: __

Emergency Phone: __

Emergency Phone: __

Blood Type: __

Blood Type: __

H.O.G. Chapter Name: __

H.O.G. Chapter Name: __

H.O.G. Membership #: __

H.O.G. Membership #: __

H.O.G. Membership Exp. Date: __

H.O.G. Membership Exp. Date: __

Country: __

Country: __

Passport #: __

Passport #: __

Passport Exp. Date: __

Passport Exp. Date: __

HOT Confirmation #: __

HOT Confirmation #: __

Bike:

Bike:

First Name: __

     

First Name: __

(upon availability)

Card Type : VISA Payment Info: Name On the credit Card: Credit Card #: Expiry Date: CVC #:

$ $ $

MC

(upon availability)

AMEX

Completed form should be submitted with full payment to local H-D Dealer. Cost above cover the bike rental fees plus SUPPLEMENTAL & LIABILITY DAMAGE insurance including all Tax. Dealer will forward complete application to MENA Office. Depending upon package and bike availability, a confirmation e-mail with all the details will be sent to the applicant. All riders & pillions should be active H.O.G. members, full or associate. All payments are non-refundable.

Registration form - After training Ride  

Registration form - After training Ride

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