Century Road Club Association
New Member Questionnaire
First Name ______________________________ Last Name ______________________
Street Address _____________________________________ Apt. # ________________
City _____________________________ State _________ Zip ____________-_______
(If you know your ZIP+4 number, please include it.)
Phone/Home ( ) __________________ Phone/Work ( ) _____________________
Fax ( ) _________________________ Email ________________________________
Date of Birth ___________________ Sex (Circle one.): F M
Membership (Circle one): Junior/Student Regular Supporter
Membership type (Circle one.): Racing Associate
Registered USCF Rider (Circle one): Yes No Pending Pro Rider
(Your USCF license must reflect CRCA affiliation! If it does not, you must have
Hilda Monaghan—NY State USCF District Rep.—change it for you.)
USCF License Number: _______________ or, PRO license number _______________
USCF Category (Circle one.) Road: 1 2 3 4 5
(Circle one.)
Track 1 2 3 4 5Age Category (Circle one.): Junior Senior Master: 35+ 45+ 55+
If you are a member of a CRCA subteam, team name: ____________________________
Occupation or field of work: ________________________________________________
Emergency contact, Name: _________________________________________________
Address: _____________________________________________________________
Telephone(s): _________________________________________________________
Emergency Medical Information: _____________________________________________
________________________________________________________________________
________________________________________________________________________
Signature Date