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Antique Vehicle Club of Mississippi
P.O.Box 55792
Jackson, Ms 39296-5792

NAME_______________________________________________DATE___________

Address___________________________________City____________

State_______Zip Code___________

Home Phone____________________Bus Phone____________________

Email Address_____________________

Occupation_________________________First or Nickname__________________

Business or Employer_______________________________________

Business Address________________________________________

Spouse first name_________________________________________

Antique Vehicle Owned___________________________________Style_____________Year__________

Antique Vehicle Owned___________________________________Style_____________Year__________

Antique Vehicle Owned___________________________________Style_____________Year__________

Antique Vehicle Owned___________________________________Style_____________Year__________

___________________________________________________________

Applicant's Signature____________________________________________

How did you hear of us?________________________________________________

Date Approved by Club________________________________President_______________________

Amount Paid___________________________ Secretary___________________________


Include $25.00 Membership fee which is renewed in October


Voting Privileges are Limited to Adult Paid Members

Thank you for your intrest in the Antique Vehicle Club of Mississippi. We hope you choose our close knit organization.