EDMONTON MOPAR CLUB   

Member Profile

Name:________________________________________________ 

Address: ___________________________________ Postal Code ___________

Phone:________________ Home _________________ Bus. ______________

E-mail:_______________________________________ Fax:_______________

IS THIS A RENEWAL OF YOUR MEMBERSHIP        ____YES     ___ NO

IF YES, DO YOU REQUIRE A WINDOW DECAL      ____ YES     ___ NO

Mopar Profile

Make: ____________________ Model: ___________________ Year_____ 

Color: ______________ Body: __________________ Engine: ________

History:______________________________________________________________________________

Memberships are free for 2010 and  includes:  Club window decal, and membership card.  Although there are no fees for 2010 you are still required to fill out a membership form to retain status with the club and remain on email and mailing lists.

By signing this document you are agreeing that any photos taken at our sanctioned events may be used on our website or used in advertising to promote the Edmonton Mopar Club.

 

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                           Signature                      Date                                 

ExecutiveUse Only: 

Method of payment: ___________ Date rec.: ______________

Decal issued: _________ Membership card: ____________Member #: __________