2012 Cruizin for a Cause
Motorcycle Tour and Rental Request

Please complete all of the following fields to reserve your Tour space!

Tour Payment will be completed in the next step.

PayPal is used to pay for tours. No Reservation will be completed until payment is received.
Last Name*
First Name*
Street Address*
Street 2*
City*
State*
Zip Code*
Home Phone*
Mobile/Cell Phone*
Rally Hotel/Motel*
Where you are staying before the Rally Cruise
Email*
Drivers License Number*
Issuing State*
Expiration Date*
MM / DD / YYYY
Date of Birth*
MM / DD / YYYY
Passport # -If not USA-*
Credit Card *

 A Major Credit Card is Required for Deposit.
Used for EagleRiders Security/Damage Deposit ONLY.
Credit Card Information will be collected at time of Rental in Florida.
Visa / MC / Discover / AmExpress / Other
Passenger Last Name*
Passenger First Name*
Rider T-Shirt Size*
Men's Med / LG / XL / XXL Women's Med / LG / XL / XXL
Passenger T-Shirt Size*
Men's Med / LG / XL / XXL Women's Med / LG / XL / XXL
Rider Helmet Size*
Med / LG / XL / XXL
Passenger Helmet Size*
Med / LG / XL / XXL
Bike Selection:
First Choice*
Available: Electra Glide Classic / Street Glide / Road Glide / Road King
Heritage Softail / FatBoy / Sportster 883 or 1200
Second Choice*