Heartland Club: Membership Information Form

2010 Heartland Club Membership Form
	Please complete this form for each member of your family. Click [Confirm Info] button at end of form. Then follow the directions to print your information and mail it with your membership dues. Thank you.

First Name:

Last Name:

Address:

City:

State: Zip:

Email:

Phone1:

Phone2: Cell:

Web Site:

Interests:

(Check as
many as
you wish!)

Volunteering:
(Check as many
as you wish!)

Host Rides/Events	Event Official/Worker	Web Site
Officer/Committee Work	Adopt-a-Highway	Publicity/Advertising

Share Your Expertise?
(Check as many as
you feel qualified!)

Briefly describe
your interests:

Select level of member- ship:

Annual Individual ($12.00)
Annual Family ($15.00)
LifeTime Member ($100.00)

For security, enter simple name for subject in picture.