Name: Applicant's Date of Birth:

Spouse (if applicable): Spouse's Date of Birth:

Address: City: Zip:

Place of Employment:

Home Phone: Work Phone:

EMail:

M/C Make: Model: License:

Engine Displacement: VIN #:

Previous Member: yes no Chapter: From: To:

Emergency Notification: Relationship:

Address: City: Phone:

I ________________________________, hereby agree to abide by the Constitution & By-laws of the Blue Knights Law Enforcement Motorcycle Club so long as I am a member. I further release the Blue Knights Motorcycle Club of any and all liability for any and all injuries, death and/or property damage received while participating in any club function, irregardless of who is responsible for the injuries, death and/or property damage.

Signature: _________________________________ Date: _______________

Sponsor/Witness Name:

Signature: _______________________________

New Member Y / N or Renewal Y / N M/C Endorsement Y / N Minimum Liability Insurance Y / N

Photocopy of Law Enforcement Identification attached with application Y / N

Committee Recommendation: ______________________________________________________________

________________________________________________________________________________________