CUSTOMER DATABASE UPDATE FORM

The following form collects information that will be used to update our internal customer database.  Privateers Harley-Davidson is committed to respecting the privacy rights of individuals. The personal information you are submitting securely through our web site is being collected and used for internal purposes only. We support and follow the principles and obligations of the Personal Information Protection and Electronic Documents Act.


Please fill out the form below as accurately and completely as possible:
* specifies mandatory fields

PERSONAL INFORMATION
*First Name:  
*Last Name:  
*Address:  
*City:  
*Province:  
*Postal Code:  
*Home Phone #:  
Cell Phone #:  
*E-Mail Address:  
 (if you do not have an e-mail address, please enter N/A)
   
Date of Birth (optional):
   
MEMBERSHIPS
H.O.G.® Member #:
H.O.G.® Expiry Date:
   
H.O.G.® Central Chapter: Yes   No
H.O.G.® South Shore Chapter: Yes   No
H.O.G.® Sou'West Chapter: Yes   No
   
Blue Knights: Yes   No
Tribe of Judah: Yes   No
Other(s): Yes   No
Please specify other group(s):
   
BIKE INFORMATION
Bike #1 Model:
Bike #1 Make:
Bike #1 Year:
   
Bike #2 Model:
Bike #2 Make:
Bike #2 Year:
   
Bike #3 Model:
Bike #3 Make:
Bike #3 Year:


 

Thank you for your assistance in helping us improve our quality of customer service.
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