| 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 Name Information |
| Full Name | |
| Mailing Address | |
| Date of Birth (d/m/y) | / - - |
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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 are your leisure time interests | |
| Religion | |
| Credit Card Holder | |
| What is your most favorite cafe / restaurant ? |
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| If You're already a H-D's owner, what is your favorite type ? |
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| If You're not a H-D's owner yet, what is dream type ? |
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| If You wish to have supplement card for minimum age 18th |
| Name on Card | |
| Id Number | |
| Sex | Male Female |
| Date of Birth (d/m/y) | / - - |
| Country |
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| Relation |
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| Type of Harley-Davidson motorcycle(s) you owned |
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