Norsemen Motorcycle Club
presents

DUAL SPORT
ADVENTURE RIDE

Registration Form

**NOTE - Incomplete forms will be rejected delaying your registration.
LIMITED TO THE FIRST 100 RIDERS
Registration closes 9/8/2012

Separate form must be filled out for each rider.

Rider First Name Rider Last Name
Rider Age Rider Date of Birth
Rider Mailing Address
City State/Province Zip/Postal Code
Email
to send information updates only
Motorcycle Make

Motorcycle Year

Motorcycle Model
Emergency Contact Name Emergency Contact
Phone Number
Passenger Name
Rider Fee

$75.00  
Passenger

$40.00
Additional Dinner Only Plates

Quantity

 $25.00  
T-Shirt *Fundraiser for local charity

Quantity

 $15.00
By checking this box you affirm the information you have provided is current and true and you understand your registration fees are non-refundable.

Print this page and send in your payment OR hit submit and you will be allowed to pay online with Paypal

If you are sending in payment, please make check payable to Norsemen Motorcycle Club and send this completed form along with your payment to:

Norsemen Motorcycle Club
c/o Leon Imholte
7301 50th Avenue
Clear Lake, MN 55319

** This is a rain or shine event so dress accordingly!