ICOA Membership Form

Please send funds in U.S. dollars drawn on a U.S. bank, checks made payable to I.C.O.A.

____ MASTERCARD	____ VISA
Card Number: _____________________________	Expiration Date: ________
Signature: ________________________________________________

Please print

Name: ________________________________________________

Phone: ________________________________________________

Address: ______________________________________________

City: _________________________________________________

State/Province: _________________________________________

Country: ______________________________________________

Zip or Postal Code: _____________________________________

E-Mail: _______________________________________________

Do you want to be listed in the Membership Directory? ____ Yes ____ No

Description of Your CBX(s): (optional)

Frame Number (VIN): __________________________________

Engine Number: _______________________________________

I understand the the International CBX Owners Association can not assume responsibility for any aspect of my safety and that, if I participate in any Association event, I do so voluntarily on my own assessment of my ability, the routes, and all facilities and conditions, assuming all risks; and I release and hold the International CBX Owners Association, its members and officers, harmless for any injury or loss to my person or property which may result therefrom. I also hereby certify that I am in compliance with my state's financial responsibility laws regarding the carrying of proper insurance.