Date        * *Road Name 
             AKA's
             
*Your email   
 First Name   
 Last Name    
 Address      
 City        * 
 State       *    Zip Code  Phone Number 
 
             Occupation (optional)
             

             MAJOR ADVENTURES ACCOMPLISHED (briefly) 
              

             PRIOR ARRESTS AND CONVICTIONS   
             

             MEDICATIONS DISCLOSURE (mandatory, but for administration purposes only)
             

           *  OTHER CLUB AFFILIATIONS (Current And Past) 
             
  
            * Why you would like to become a Long Rider
             

 * I,, avow that the above information is true.

   I am aware that embellishment of my credentials may subject this

   application to denial. I also avow, should my application

   be accepted, that I understand and will abide by the Long Rider Creed

   and show respect for the Long Rider patch at all times.

* Required