First Name
Last Name
Street Address
Suburb
Town/City
State/Territory
Postcode/Zip
Country
Email Address
Phone Number
BIKE FIRST CHOICE
BMW F650 GS Dakar (2004) BMW F800GS BMW R1200GS Harley-Davidson FLHT Electra Glide Harley-Davidson Super Glide 1584 Harley-Davidson FXD Fat Bob 1584 Honda ST1300 Honda VT750C Shadow Suzuki GSX1300 B-King Suzuki 1200 Bandit Suzuki DL650 V-Strom Suzuki DRZ400E (2005) Suzuki DRZ250E Triumph Rocket III Touring Triumph Street Triple 675 Triumph Speedmaster Triumph Tiger 1050 Please Select
SECOND CHOICE
BMW R1200GS BMW F800GS BMW F650 GS Dakar (2004) Harley-Davidson FLHT Electra Glide Harley-Davidson Super Glide 1584 Harley-Davidson FXD Fat Bob 1584 Honda ST1300 Honda VT750C Shadow Suzuki GSX1300 B-King Suzuki 1200 Bandit Suzuki DL650 V-Strom Suzuki DRZ250E Suzuki DRZ400E (2005) Triumph Rocket III Touring Triumph Street Triple 675 Triumph Speedmaster Triumph Tiger 1050 Please Select
First Day of Hire
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April may June July August September October November December 2008 2009 2010
Last Day of Hire
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2008 2009 2010
Riders Licence No.
Licence Expiry Date
Date of Birth
Helmet Size
XS S M L XL Own
Jacket Size
S M L XL XXL Own
Comments or extra information that you may wish to provide.
Credit Card Type
Visa - Mastercard
Card Number
Expiry Date
Month Year
Name on Card
Deposit Amount(20% of total rental charge. Minimum of $50)
AUD
Card Holders Signature
Please PRINT OUT this form, remember to SIGN IT and then FAX it to us at +61 75474 1333 If faxing within Australia use 07 5474 1333
