STARTING FORM (Point of Departure)       PLEASE TYPE OR PRINT CLEARLY

RIDERS NAME _____________________________________________________________  Male __ Female __
RIDERS EMAIL _________________________________                                              
RIDERS PHONE _______________________________________________________________________                                  

RIDERS FULL MAILING ADDRESS ______________________________________________________________________

_______________________________________________________________________________________________                                                                     

Name of Long Distance Ride (check one)
___ Easy Rider 500 miles in 12 hours
___ Full Throttle 1000 miles in 24 hours
___ King of the Road 1500 miles in 36 hours
___ Born to Be Wild Coast to Coast in 48 hours

Long Distance Ride in Kilometers 
___ Easy Rider 805 kilometers in 12 hours (km*)
___ Full Throttle 1610 kilometers in 24 hours (km*)
_______King of the Road 2415 kilometers in 36 hours (km*)                                                                                                                                    
                                                                                                                                                                                                                                           
(*Eligible only to LDR members residing outside of the United States or where kilometers are a standard unit.) 

START DATE__________________________________________________________

START TIME__________________________________________________________

STARTING LOCATION_____________________________________________________________________

STARTING ODOMETER READING____________________________________________________________

TYPE OF MOTORCYCLE USED_______________________________________________________________

WITNESS NAME (PLEASE PRINT) ____________________________________________________________

WITNESS SIGNATURE______________________________________________________________________

WITNESS PHONE NUMBER__________________________________________________________________

ENDING FORM (Final Destination)

END DATE __________________________________________________

END TIME __________________________________________________

END LOCATION _________________________________________________________________

END ODOMETER READING ________________________________________________________

TYPE OF MOTORCYCLE USED ______________________________________________________

WITNESS NAME (Print Please) _____________________________________________________

WITNESS SIGNATURE ____________________________________________________________

WITNESS PHONE NUMBER ________________________________________________________

I, __________________________________________________ (rider's name) guarantee that the information included on these forms and verified by the enclosed receipts, are a true and actual account of my Long Distance Ride according to the rules set forth by Long Distance Riders.

The initial cost for your certification is $35.00 payable to "Long Distance Riders". This includes your designation certificate, authentic LDR patch showing achievement, an LDR decal, and an LDR Bad to the Bone license plate frame. Unless you are from a country other than the USA where the license frame will not fit your motorcycle license, we will substitute with an LDR Member Patch.  The merchandise order form can be found on page 3 of this document.  Florida residents add 7.5% sales tax.

Please send completed certification forms, receipts, documentation, maps and checks to:
Jack R. Powis, Jr 6601 Donerail Trail
Tallahassee, FL 32309

Or email documents to:  jackp210@aol.com

If you are paying by Pay Pal (icon is on our web site), we must receive notification of payment before your certification process can begin.  

Please Note:  If you are a rider from a country other than the USA, your package must be sent through customs mail.  Although we take great care in preparing your package for mailing, packages do go missing, therefore LDR will not be responsible for any packages that have been lost in the postal system.
Long Distance Riders Merchandise Form           Rider’s Name: _______________________________________
In order to purchase merchandise, you must complete a Long Distance Rider’s qualified ride.  If you complete a King of the Road 1500 mile ride, you can purchase the Full Throttle 1000 mile and Easy Rider 500 mile merchandise as well.
LONG DISTANCE RIDERS MEMBERSHIP PACKAGE                                        Price		Quantity	   Total    Includes certificate, designation patch, decal, and license plate frame                  $35.00		   _____	  	$_____         ______Check here if you are from another country other than USA.                                                                                                                             (Your package will include an LDR Member Patch instead of the license frame.)
ADDITIONAL Certificate of the same designation as your certified ride         6.00		   _____		$_____ ADDITIONAL Certificate of another designation  (please specify)                 12.00		   _____		$_____          ____Easy Rider 500                                                                                                                                                                                                          ____Full Throttle 1000                                                                                                                                                                                              ____King of the Road 1500                                                                                                                                                                                      ____Coast to Coast                                                                                                                                                                                                 ____Easy Rider 805 km                                                                                                                                                                                       ____Full Throttle 1610 km                                                                                                                                                                                     ____King of the Road 2415 kilometers                                                                                                  
PATCHES                                                                                                                                                                                                                _____Easy Rider 500					                                     7.00                      _____	  	$______                                                                                                                                                                                       _____Full Throttle 1000	                                                                                                     7.00                      _____	  	$______                                                                                                                                                                                            _____King of the Road 1500                                                                                                  7.00	                    _____	  	$______      _____Born to be Wild Coast to Coast                                                                                   7.00 	                    _____	  	$______                                                                                                                                             _____Easy Rider 805 kilometers	                                                                                     7.00                       _____	  	$______                                                                                                                                                                 _____Full Throttle 1610 kilometers	                                                                                     7.00                       _____                $______                                                                                    _____King of the Road 2415 kilometers                                                                              7.00	                    _____	  	$______               _____Bad to the Bone MEMBER patch                                                                                7.00	                    _____	  	$______    
PINS – No kilometer pins available                                                                                                                                                                                                                      _____Easy Rider 500	                                                                                                     7.00	                     ______	$______                                                                                                                                                                                         _____Full Throttle 1000	                                                                                                     7.00	                     ______	$______                                                                                                                                                                                                                                                               _____King of the Road 1500	                                                                                     7.00	                     ______	$______                                                                                                                                                                                                                                                                                                   _____Born to be Wild Coast to Coast                                                                                   7.00	                     ______	$______                                                                                                                                                                                         
OTHER MERCHANDISE AVAILABLE                                                                                                                                                  _____ Long Distance Riders Key Chain				                      3.00		      ______	$_____                        _____ Long Distance Riders License Plate Frame			                      6.00		      ______	$_____                        _____ Long Distance Riders Decal						      4.00		      ______	$_____                          _____ Long Distance Riders Beverage Koozie			                      4.00	                      ______	$_____       _____ Long Distance Riders Kick Stand Disc                                                                        5.00                         ______            $_____
LONG DISTANCE RIDERS SHORT SLEEVE T-SHIRTS 
Size and Price List – SM to XL cost is $25.00, size 2X and size 3X will be $26.00.     Designations are in miles or kilometers.                                                                                                    
_____Easy Rider*                     ____ miles or _____km              _____Size	_____Price	_____Quantity	$______                          _____Full Throttle*                  ____miles or _____km              _____Size	_____Price	_____Quantity	$______                 _____King of the Road*          ____miles or _____km              _____Size	_____Price	_____Quantity	$______              _____Coast to Coast* 			                           _____Size	_____Price	_____Quantity	$______                  _____LDR Original Design			                           _____Size	_____Price	_____Quantity	$______                  _____Bad to the Bone Member Shirt – White                          _____Size	_____Price	_____Quantity	$______                     _____Bad to the Bone Member Shirt - Black                            _____Size   _____Price	_____Quantity	$______
                                                                                    FLORIDA residents add 7.5% Sales Tax     $________                                                                        Shipping and Handling (US $5.00/International $20.00)   $________     
                                                                                                      Final Form Total (via Pay Pal or Check)   $________   
 *Designation T-shirts are discontinued.  Available while supplies last.