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North Carolina Bicycle Club Membership Form
Categories
Individual -
$15.00
Family member name
Email
First Name
Last Name
Country
-- select country --
Canada
International
United States
Address
City
State
-- select state --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Col.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
-- select state --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Col.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
-- select province --
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Zip Code
Phone
Emergency Contact
Emergency Phone
Comments or suggestions
Waiver
I have read and agreed to the TERMS
CLICK HERE TO VIEW THE TERMS
.
Is the participant 18 or older?
18 or older
Under 18
Parent or Legal Guardian’s Signature - By providing your electronic signature you agree that you have the authority to register these participants and agree to the waiver(s) for them as their parent or legal guardian.
If registering a child under 18, you are consenting to the collection of the child's information that you are providing for the purposes of registration.
Parent's signature
Password
Confirm Password
Check Out and Pay
Discount or Tracking Code
Apply
Do not COPY & PASTE the code, please type it into this field.
Dummy (v6)
Price
$
Discount(-)
$
Prior Payment(-)
$
available $
remaining $
Deferred(-)
$
available $
0.00
remaining $
0.00
Credits(-)
$
available $
0.00
remaining. $
0.00
Net Amount
$
Shipping
$
Service
$
Total
no handling
$
Handling
$
Sales Tax
$
Refund Protection
$
coverage $
Donation
$
Total Amount
$
Total Invoiced
$
Total Owed
$
Payment Method
The payment and credit card section is not visible because there is nothing owed or form fields have not been fully completed.
Visa
Mastercard
Payable To:
Address:
click the "submit" button to submit your order then send a check to (or pay in person at) the address above.
1. Venmo the total amount to the Phone #:
2. Make sure you enter the code,
42250
in "What's it for".
3. Click the "pay now" button.
Enter a Check Number
Enter a Check Amount
Send email receipt to the participant
Send email receipt to the participant
Purchase
Purchase
Cancel
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