On line membership Payment form

Freedom of Road Riders^® Inc.

Online Payment Center

Complete the form below
Click on the “PlaceOrder” button
Then click on the “Buy Now” button
This will take you to PayPal (a secured site).

We accept MasterCard, VISA, Discover or your PayPal account.

Membership dues are $25.00

Event Insurance $85.00 per event
$60 per additional insured
$90 additional per million to raise coverage

Fields with an " * " are required and must be entered.

	New Member *	Yes No
	Last Name *
	First Name *
	Address *
	Apartment / Box #
	City *
	State *
	Zip *	--
	Phone *	----
	Email address
		If you have an email address please let us know
	Local *
	Membership #
	Registered Voter	Yes No
	Recruited by: or Event Name: