Lonerider Membership Form

The Lonerider International Fan Club

Membership Form

Annual membership fee is $15 per person
(Outside U.S., including Canada, fee is $18 U.S. per person)
Please send check or money order (do not send cash)
Please allow 3-4 weeks for delivery of your initial fan club membership package.

Print out this page, fill out the form below, and return with your check or money order made payable to:

Lonerider
P.O. Box XXXX - Germantown, MD 00000
Attn: Fan Club

Name: _________________________________________________

Street Address: __________________________________________

P.O. Box: ______________________________________________

City: __________________________________

State: ___________ ZIP Code: ____________________

Date of Birth: (Month, Day and Year)__________________________

E-Mail Address: __________________________________________

Phone: Day (____) _____-_________ Evening (____) _____-__________