American Legion Riders

American Legion Riders Department of California,
District 22, Post 416
210 West F Street, Encinitas, CA 92024-3525
Application for Membership and Release of Liability

Last Name:       First Name: 

Road Name:      DOB: Month: Day: Year:

Address:           City:    State:    ZIP Code:

Home Phone: ( ) -        Cell Phone: ( ) -

E-Mail Address: 

District # 22   Chapter: 416     Legion:      Auxiliary:      SAL:      Member #:

Cycle Make:       Model:     CC:

License Plate:     Drivers License #:

Owner:    Spouse:    RDP*:      Member Name (if Spouse/RDP):

Emergency Contact Name:      Phone ( ) -

I agree that the ALR 416 back patch is the property of the American Legion Riders, Chapter 416 and must be returned to the American Legion Riders, Chapter 416 upon my resignation, suspension, or termination of membership in the American Legion Riders, Chapter 416, the American Legion, the American Legion Auxiliary or the Sons of the American Legion. I agree that I will purchase the ALR 416 back patch within sixty (60) days of the Chapter's acceptance of this application or forfeit dues paid.

Rider Signature ____________________________________________ Date _______________

Witness Signature __________________________________________ Date ________________

*RDP = registered domestic partner.