NC BikePAC Application

Application for Membership

___ Copper Level $25.00
___ Silver Level $50.00 to $100.00
___ Gold Level $100 and over or monthly sustaining membership

Join and receive a vest pin just like the BikePAC logo!

If you would like to make a donation and not become a member, please note the donation amount here: ______________________

New Member __ Renewal __

DATE__________________________________________

NAME__________________________________________

ADDRESS_______________________________________

CITY___________________________________________

STATE___________________ ZIP___________________

OCCUPATION___________________________________

EMPLOYER_____________________________________

PHONE (Not required)_____________________________

EMAIL (Not required)______________________________

Registered Voter? YES ? NO ?

Do you belong to a motorcyclists’ rights group (s)? If so, which one (s)? _______________________________________________
_______________________________________________

Mail this completed form with your personal check to:

NC BikePAC
PO Box 1554
Shallotte, NC 28459

Membership is not tax deductible. 100% of the monies received are used for lobbying, education and support of elected officials and candidates of North Carolina who endorse the goals and objectives of NC BikePAC.