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. |