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Application
PHRNA

   PURPLE HEART RIDERS ASSOCIATION   MEMBERSHIP

   COMPLETE APPLICATION  AND MAIL TO: This is the online secured version, a paper version may be required from you at a later date. Thank you...

   PURPLE HEART RIDERS ASSOCIATION     P.O. BOX 892, NASHUA, NH 03061    

   LIFE MEMBERSHIP FEE: $70.00    

 The Purple Heart Riders are a brotherhood of Combat Wounded Veteran Motorcycle Riders

Membership in the Purple Heart Riders is restricted to those American Military Veterans who have been awarded the Purple Heart Medal for Wounds Received in Combat. There are no execptions. You are eligible to become a member of this very restricted and prestigious organization of motorcycle riders and wear our Colors by the very fact that you are a Combat Wounded Veteran, received the Purple Heart Medal and own and ride Motorcycle of 500cc or greater. Upon verification of your Award and approval by the National Board, you will be vested with all rights and privileges of general membership. You must understand and appreciate that we verify that you are indeed a recipient of the Purple Heart Medal and it is a requirement you submit a copy of your DD214 demonstrating the Award. 

Security

Security
About SSL Certificates
1. PRINT YOUR FULL NAME*

PRINT YOUR FULL NAME*
2. HANDLE/NICK-NAME

HANDLE/NICK-NAME
3. DATE OF BIRTH/ AGE

DATE OF BIRTH/ AGE

Date
4. PERMANENT RESIDENTIAL ADDRESS*

PERMANENT RESIDENTIAL ADDRESS*
5. CITY*

CITY*
6. STATE*

STATE*
7. ZIP CODE*

ZIP CODE*
8. HOME PHONE*

HOME PHONE*
9. CELL PHONE

CELL PHONE
10. BUSINESS PHONE

BUSINESS PHONE
11. E-MAIL ADDRESSES (for notification and updates)*

E-MAIL ADDRESSES (for notification and updates)*
12. MILITARY SERVICE

MILITARY SERVICE
13. CONFLICTS YOU WERE IN

CONFLICTS YOU WERE IN
14. Date Wounded/ PHM Award

Date Wounded/ PHM Award

Date
15. ENGAGEMENT/ CAMPAIGN*

ENGAGEMENT/ CAMPAIGN*
16. NUMBER OF PH AWARDS*

NUMBER OF PH AWARDS*
17. DATE ENTERED SERVICE

DATE ENTERED SERVICE

Date
18. DATE OF DISCHARGE

DATE OF DISCHARGE

Date
19. HIGHEST RANK*

HIGHEST RANK*
20. SERVICE NO./SSN NO.*

SERVICE NO./SSN NO.*
21. MOPH NO.*

MOPH NO.*
22. VA CLAIM NO. (PH Designation)*

VA CLAIM NO. (PH Designation)*
23. MUST SUBMIT ONE OF THE FOLLOWING DOCUMENTS

MUST SUBMIT ONE OF THE FOLLOWING DOCUMENTS

One of the following documents must be submitted with the Membership Application. Active Duty please submit a copy of Orders awarding the PHM. If your a Veteran, please submit the form that demonstrates the award of the Purple Heart Medal and Honorable Discharge from Service. The Purple Heart Certificate alone does not constitute proof of the award (they are commercially available w/o proof of award.
24. DRIVER LICENSE NO.*

DRIVER LICENSE NO.*
25. Date of EXPIRATION

Date of EXPIRATION

Date
26. STATE OF ISSUE*

STATE OF ISSUE*
27. MOTORCYCLE ENDORSEMENT (if required Y/N)*

MOTORCYCLE ENDORSEMENT (if required Y/N)*
28. CONCEALED HANDGUN PERMIT NO.*

CONCEALED HANDGUN PERMIT NO.*
29. Date of EXPIRATION

Date of EXPIRATION

Date
30. STATE OF ISSUE*

STATE OF ISSUE*
31. Terms and Conditions

Terms and Conditions

I hereby apply for the Purple Heart Riders Association and agree to abide by all Association Rules and By-Laws. I understand that the Colors/ Back Patch and any item displaying the official logo of the Association are proprietary images. Colors are 'awarded' as a Privilege of Membership but remains the property of the Association and must be returned upon demand or resignation. 
I have read and accept these terms and conditions.
32. CHOOSE MEMBER PACKAGE

CHOOSE MEMBER PACKAGE
33. SIGNATURE OF Applicant*

SIGNATURE OF Applicant*
34. APPLICANT SPONSORED BY: PHR member name*

APPLICANT SPONSORED BY: PHR member name*
35. Date

Date

Date
36. Verifier

Verifier

For security purposes, we ask that you enter the security code that is shown in the graphic. Please enter the code exactly as it is shown in the graphic.
Your Code
Enter Code