Riding   Club                
                                             Prospect Application

Last name:    __________________________First name: _______________  MI__



Spouse/significant other's name: __________________________________

Phone:  (home)______________________(cell)_____________________


Check one: ___Active public safety___Retired public safety
       ___Active duty military ___Retired military
       ___Spouse of member                ___Veteran

Public safety agency / branch of service/years of service:  _______________________

Year/make/model of motorcycle:             _______________________

Who or what introduced you to the club? _______________________

Have you ever been convicted of a felony?_____

Have you ever been a member of  or affiliated with  a 1% support group? _____

I understand that my application for prospect status does not guarantee approval of full membership in the FREEDOM RIDERS USA and that approval of membership requires
that I read, understand and abide by the Club By-Laws.  A club member is normally
required for introduction and sponsorship to the club.  Application must be submitted
with initiation fee (see sponsor for details).  Application is not required to attend club
meetings or rides.

___________________________________________Received by: ________
SignatureDate   Initials/date

Freedom Riders USA
P.O. Box 93
Quaker Hill, CT  06375