MEMBERSHIP APPLICATION

New Member (1) ___ (2) ____

Renewal (1) ___ (2) ___

Member # (1) _________ (2) _________ -if current member

Date ______________

Name (1) _____________________________________________________________

Name (2) _____________________________________________________________

Address _______________________________________________

City _______________________________________ State ________ Zip _____________

Membership type (check one)

Individual (single) ___ $15.00

Individual (couple) ____ $25.00

Sustaining ___ $100.00 (web link information online @ membership)

Corporate Sponsor _____ $250.00 (will need ad design for newsletter or information;

web link information for online) Contact phone _________________________

Make check or money order payable to: Illinois Motorcyclist's Rights Association, Inc.

Membership dues paid to I.M.R. A., Inc. are not tax deductible. All membership dues for period of one (1) year.

Member(s) must be 18 years of age or older. Signature(s)

(1)__________________________________________________

(2)__________________________________________________

I agree to hold harmless the Illinois Motorcyclist's Rights Association, Inc., it's Directors and members from litigation, lawsuits or claims pertaining to use of any information resource through the organization (written, verbal or electronic). I understand the final determination and/or verification is the sole responsibility of user(s). An event listing through this organization does not constitute sanctioning by this same organization; participation is always voluntary and participants assume all risks (personal and/or property) and any liability for such.

A membership shall be non-assessable, non-refundable, non-transferable and non-assignable.

Print form and mail to:

Illinois Motorcyclist's Rights Assoc., Inc.

PO Box 133

Galesburg, IL 61402-0133

Phone Fax 309-289-4880

__________________________________________________________________________________________

TEMPORARY RECEIPT Please allow 3-4 weeks for Processing Applications Amount Paid __________ Date Paid _________ Check# ______ / Money Order# __________ (This is your receipt until you receive your membership card)

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