Egypt Trike Patrol

Membership Application/Renewal

 

 

Name: ____________________________ Member Temple #:___________

 

Ladies Name: ________________ Children(s) Name: _________________

 

Address: _______________________ City: ___________  ZIP: _________

 

Phone # Cell: _______________ Work: ____________ Home: __________

 

Email Address: ________________________________________________

 

***** MUST HAVE FOR INSURANCE *****

 

Trike VIN # Engine: _________________ Frame: ____________________

 

Drivers Lic. State: __________ Number: ____________________________

 

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Special Interests:

 

 

 

I certify that I am a member in good standing with Egypt Shrine and that I will abide by the by-laws of the Temple and the Trike Patrol.

 

Noble Signature: _______________________   Date: __________________

 

Print Name: ___________________________________________________