To join the Motorcyclists for Jesus Ministry,
please
print form and mail to:
Motorcyclists for Jesus Ministries
693 West Westbrook Road
Brookville, Ohio 45309
937-833-3818
FAX 937-833-0048
Annual Dues $15.00 Single / $25.00 Couple
Lifetime Membership $200.00 Single /
$300.00 Couple
Name______________________________________________________
Check here if your a born again Christian [ ]
Church Affiliation_____________________________________
Day Phone (____)______________ Fax:
________________
E-Mail ________________________________
Age _________ Date of Birth
_________________
Signature _____________________________
Spouse______________________________________________________
Check here if your a born again Christian [ ]
Church Affiliation_____________________________________
Day Phone (____)______________ Fax:
________________
E-Mail ________________________________
Age ______ Date of Birth __________ Anniversary ________
Signature _____________________________
Street Address_______________________________________
_____________________________________________________
City__________________________________________________________
State____________ Zip____________________
Motorcycle Club Affiliation [s] ___________________________
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