LongRider Registration

AMA LongRider Application

AMA LongRiders must provide verification information and program registration fee with this application.
Name*

First NameLast Name
AMA Number*
Years Riding*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Make/Model of Motorcycle 1*
Years Owned*
Odometer*

Signature (I certify that the milage above is true and accurate)*

Clear
Date Submitted*

MonthDayYear
Verification Documentation (Choose One and Attach)*

Odometer Photo (Include AMA Card in Photo)Club Verification/AwardDealer Letter/Service Document
Upload Verification Documentation*

10 MB total upload size. File types accepted (pdf, doc, docx, zip, jpg, jpeg, png, gif)
Cancelof

Payment Information*

RegistrationIncludes 1 AMA LongRider Patch and 1 Decal

$20.00

Additional Patches

$7.50 Quantity

Additional Decals

$5.00 Quantity

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

AMA LongRider Application