PUSH RODS CAR CLUB    

 

APPLICATION FOR MEMBERSHIP

 

Type of Application                                                                                        Date: _______

 

Regular __ Special __ Previous Member __

                                                           

Name:

Home Phone:

Address:

Birth Date:

City:    

SS#:

State:   

DL#:

Zip Code:

Insurance Co.:

Employer:

Wife’s Name:

Occupation:

Children under 18:

E-mail:

 

 

                                   

 

 

 

Cars of Interest; Make, Model, Year:

 

_____________________________________________________  Runner __ Project __

 

_____________________________________________________  Runner __ Project __

 

_____________________________________________________  Runner __ Project __

 

Special Skills or Interests that might be useful to the club:

 

 

 

 

 

Any Felony convictions in the past 5 years: Yes __ No __

 

 

__________________________________

Approved: Membership Committee                 

 

 

___________________________________

Sponsor: