PRE-REGISTRATION DUE NO LATER THAN

APRIL 1ST, 2007

Rider’s Name: ______________________ Shirt size: M  L  XL  XXL XXXL

Signature: _______________________________ Date: _________

Passenger’s Name: __________________ Shirt size: M  L  XL  XXL  XXXL

Signature: _______________________________ Date: _________

Credit Card Type: Visa        ___     Master Card ___

Credit Card Users Name: _________________________________

Credit Card Number: _ _ _ _ - _ _ _ _ - _ _ _ _ - _ _ _ _

Expiration Date: Month _ _ Year _ _ _ _ Security Number: _ _ _ _

Card Signature: _________________________________________

Please make checks payable to: Mohave Shrine Club

Once registered, no refunds will be issued. Please mail this form with check or credit card info to:

2580 Miracle Mile

Bullhead City, Az 86442

(928) 758-5113, Fax 928-704-4930

msba@frontiernet.net