$159*

$169* after
February 21st

Long Island Ravens MC
20th Anniversary
 Weekend Run Application
March 17-18, 2012
Holiday Inn MacArthur Airport, Ronkonkoma, NY

Join the Brothers of the LI Ravens in celebrating our 20th year of brotherhood, loyalty and pride in the leather community.  We invite our friends for a weekend party on Long Island.

Payment may be by Credit Card or Check/Money Order. Cash is accepted only if transmitted directly through a LI Ravens MC full brother (please get a receipt). We process all credit cards through PayPal. They accept American Express, Discover, MasterCard, VISA. You do not need to be a member of PayPal to make a credit card payment. If using a credit card, we request the Credit Card's Security Code.

Host Hotel:  Ronkonkoma Holiday Inn.  $99 per night.  Make hotel reservations directly with the Holiday Inn, 631-585-9500.  Be sure to mention the LI Ravens MC.  Any problems or questions, contact our Hotel Coordinator Chaz B. 516-887-4538, hotel@liravensmc.org. 
Visit Hotel Information at http://PrometheusLI.com/RavensStore/HotelInformation.htm

Please fill out application, one person per form
Mail To:  LI Ravens MC, c/o John Deitz, 7 Locust Rd., Brookhaven, NY 11719
Telephone:  John Deitz, Registrations Chair, (631) 286-3178.  Email: registrations@liravensmc.org

Name:
 		 Telephone:
 
Address:
 		 City, State, Zip:
 
Email:
 		 Organization Affiliation (if any):
 
Special Requirements, such as special nutritional or room requirements:
 		 I plan to arrive:  [  ] Friday evening   [  ] Saturday
Other:
I plan to stay at the Holiday Inn:    [ ] Yes    [ ] No
(if yes, please make reservations directly with the Holiday Inn (see above).
Room type:  [  ] Two Queens beds      [  ]  One King sized bed
Smoking Room?  [  ] No    [  ] Yes (very limited availability in adjacent wing)
Roommates?:
 
______ Weekend reservations at $159* each ($169* after February 21, 2012)
 Anniversary T-Shirts each $20 additional -- please indicate size and quantity:            Total t-shirts = [   ]  [   ] Small    [  ] Medium    [   ] Large
 [   ] X-large    [   ] XX-large
Total Remittance:
 $
Payment Method:   [ ] Check/Money Order
  [ ] Visa    [ ] Mastercard  [ ] American Express  [ ] Discover
Account Number:
 

I hereby certify that I am 21 years of age or older and that I will abide by all rules and regulations pertaining to this event. I will not use illegal drugs, perform illegal acts, or hold the LI Ravens MC, Inc. or participating venues responsible for damages or personal injuries to my personal property or self.  This is a private event; the L.I. Ravens M.C., Inc. reserves the right to refuse admission or eject any person for any reason whatsoever.
Expiration Date (mm/yy) Security Code:
 
Name on card:
 
Billing Address if different from address above:

 
Your Signature:
 

* The cost of a registration includes $1 per person as a Participating Associate membership fee.  This fee entitles the registrant to all the privileges of Participating Associate membership in the LIRMC, Inc. for a period of three months.

Page Revised:  27 November 2011