| Please fill in this form using the same name as it appears on your ID Card |
| Mr Mrs Ms Miss Others |
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| Customer Information |
| Full Name | |
| Mailing Address | |
| Place & Date of Birth (dd/mm/yy) |
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| Office Information |
| Occupation | |
| Position | |
| Office Address | |
| City / Zip Code | / |
| Country | |
| Telephone | |
| Fax Number | |
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| Home Information |
| Home Address | |
| City / Zip Code | / |
| Country |
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| Telephone | |
| Fax Number | |
| Mobile Phone | |
| What is your activity in your leisure time |
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| Religion | |
| Credit Card Holder | |
| Cafe / Restaurant that you visited mostly? |
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| If You're already owned your Harley-Davidson motorcycle, which type is your favorite? |
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| If You're haven't got any opportunities to own one of the Harley-Davidson motorcycle an you are interested in having it, which type do you want to choose? |
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| Do you wish to have a supplement card? |
| Full Name |
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| Id Number | |
| Gender | Male Female |
| Place & Date of Birth (dd/mm/yy) |
/ - - |
| Country |
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| Relation |
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| Type of Harley-Davidson motorcycle(s) which already owned by you ? |
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By fill in this application form, I agree to join and follow all requirements should be completed for joining the membership of MHD Preferred Card and agree to all terms, conditions and requirements for the membership. |
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