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Name:		Business Phone Contact:
Address:		Home Phone Contact:
		Mobile:
Date of Birth:		Email Address:
Next of Kin:		Email Me Newsletters Please (Y/N):	Yes  / No
Next of Kin Contact:		Next of Kin Address / Phone:
Doctors Name:
Address:
MNZ Licence Holder:	Yes  / No    (cross out one)	Existing Member:             Yes  / No
I am interested in the following (tick boxes that apply):
Road Racing	c	Dirt Riding	c
Motocross	c	Supermotard	c
Trials	c	Cross Country Racing	c
Enduro	c	Trail Rides	c
As ticked above but I am also interested in:
I am prepared to assist in running some events:     Yes  /  No      (Please assist where you can, don't leave it to the same people every time, they have lives too.)
I am not prepared to assist in running some events and would rather leave it to everybody else:                               (answer not compulsory)
SUBSCRIPTIONS ARE: Adults $20 Juniors $15 Family $25
Signature:		Date:
Subscriptions To: Te Puke Motorcycle Club P O Box 167 Te Puke