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

Please send copy of your ID card, copy of STNK, & copy of H-D club member card to
email: customerservice@mhd.co.id / fax# 021-72796409 cq. Marcomm Dept.

By filling 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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Mabua Harley-Davidson , a member of MRA Group Automotive Division  Jl. Iskandarsyah Raya No. 1, Jakarta 12160   Phone. (62-21) 720 6606   Fax. (62-21) 722 3769
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