Ride Date:
May 19, 2012
Starting Location:Harley Davidson of Cartersville
Cartersville,Ga.
Payment Type:
Check:_________. Please make check payable to Alyssa Leonard
Mail to:
Alyss's
Ride Foundation
P.O. Box 61 Taylorsville, Ga. 30178
Credit Card______
Type, M/C or Visa
( Please cirule one )
Name on Card _________________________________________________________________________
Address______________________________________________
State___________ Zip______________
Account #____________-______________-_______________-_______________
Expiration
Date________Month____________Year_____________
CVC#______________( 3-Diget on Back of Card )
Amount approved
to be deducted from your account $______________
Sign_______________________________________Date___________________
Please
mail Signed Registration form along with payment to:
payable to ALyssa Leonard
Alyssa's Ride Foundation
P.O.
Box 61, Taylorsville, GA. 30178