| 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 | / |
| Country |
|
| 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 an 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 ? |
|
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.
|
| |
|
