Buffalo Soldiers Kentucky Membership Application

(Please complete form and give to any member)

1.  Name:                                                 

     AKA:                                               

    Spouse Name:                                        

2.  (Female member only) Maiden Name:                                                     

3.  Address:                                                            

   City, State, Zip code:                                                 

4.  Phone Numbers: Home                     Cell:                        

5.  Email Address:                            

6.  Occupation:                               

7.  Marital Status:                      Number of Children                

8.  Military Affiliation:                  Years of Service                   

9.  Do you agree to a criminal background check at your expense?                                 

10.  Do you own a Motorcycle?  If yes, Make:                    Model:                     Year:                   

    If no, are you willing to purchase one within 6 months of acceptance into the club?          

11. Are you now or have you ever been a member of another Motorcycle club?  When:         , name of club:          

12. Be available to speak publicly (1) once during your probationary period and (1)once annually as member.

13. Tell us why you would like to be a member of the Ky. Buffalo Soldiers M/C:

14.  Date of Birth:                          

15.  SSN:                                      (needed for back ground check only)

16.  Do you have any health issues that may require assistance yes      ,no     .

    Explain                                                           . 

17.  Emergency contact information (Next of Kin): 

Name:                                                                                                                      

Address:                                                                                                                                                   

Phone #:                                               

18.  I fully understand that the chapter colors purchased by me are the property of the National Association of Buffalo Soldiers Motorcycle Club (NABSMC) and must be returned to the chapter if I am no longer a member of the club.

19.  The Buffalo Soldiers logo is solely the registered trademark ® of the NABSMC. Permission to use this image must be granted by Ken Thomas.

Signature:                                                                                         Date:                                                         .