CMC Texas 121st Application FieldsetBasic Pre-requisites *Check each line as they apply to you. If you cannot check each line, you cannot become a Countrymen member.I am a male, twenty-one years of age or older.I have unrestricted access to and ride a cruiser, bagger or similar style motorcycle.I agree to learn, adapt to, and abide by CMC culture, doctrine, expectations.I agree to follow all lawful verbal instructions from patched members and officers.I have not previously served and I do not currently serve in law enforcement with arrest authority in the same state as the chapter I desire to join.I am not "out bad" from another motorcycle club.I have not been charged for assault/indecency against women or childrenI do not use/abuse narcotics or prescription drugsI was not dishonorably discharged or given an "other than honorable" discharge from the U.S. military Personal InfoFull Name *Email Address *Phone Number *Date of Birth *Address *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryShort Sleeve T-Shirt Size *-- SELECT ONE --SMLXLXXLXXXLLong Sleeve T-Shirt Size *-- SELECT ONE --SMLXLXXLXXXLHoodie / Sweatshirt Size *-- SELECT ONE --SMLXLXXLXXXL License and CoverageWhat do you ride? *Year, make, model and engine size (CCs of CIs) of your motorcycle(s).Proof of Insurance *Upload a copy (image or PDF) of your current insurance card covering the motorcycle(s) you'll ride in the group.Proof of License *Upload a copy (image or PDF) of your current driver's license showing a motorcycle classification.Facebook Profile Copy and paste the URL to your Facebook profile page Military ServiceSelect the branch(es) in which you served: *U.S. Air ForceU.S. ArmyU.S. Coast GuardU.S. Marine CorpsU.S. NavyI did not serve in the military (proud supporter)Service Summary Optional; tell us briefly about your service Criminal BackgroundWhat criminal convictions will appear on your criminal background check? *If none, write 'none'. Emergency Contact Info Please provide the following information to be used in an emergency situation.First Name Last Name Relationship to You Primary Phone Alternate Phone Medical Info This information is confidential and will only be provided to emergency medical personnel if they are calledWhat is your blood type? *-- SELECT TYPE --O +O –A +A –B +B –AB +AB –Do you have any known allergies? If so, please list. Any medical conditions that should be made known to emergency services personnel? Agree to terms *I do swear or affirm the information provided is accurate and true to the best of my knowledge.Full Name * VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>: