Date ______________________________ New               Renewal    

Name _________________________________________________________________ Birth Date ________________________

Spouse ________________________________________________________________ Birth Date ________________________

Address _______________________________________________________________ Phone ___________________________

City ____________________________________________________ State _______________________Zip_________________

Occupation __________________________________________________________________________________________

Spouse Occupation________________________________________________________________________________

E-Mail Address ___________________________________________ Web Site ____________________________________

Make & Model of Mopar Auto’s (List up to five) _______________________________________________________________

________________________________________________________________________________________________________

Would you be interested in a Board member or committee job? Yes No Maybe

If so, what qualifications or interest do you have______________________________________________________________

________________________________________________________________________________________________________

Any suggestions as to the type of activities in which you would like to see the club participate?

________________________________________________________________________________________________________

Please return completed form and $ 15.00 membership dues to: Lilac City Mopars Unlimited
P.O. Box 7206
Spokane, Washington 99207

Membership entitles you to the following: Membership card, Newsletter, and parts discounts at participating dealers/businesses.

FOR MORE INFORMATION CALL:
Bob Tifft  467-6135  Jim Hofer 993-8264  Bud Merritt 467-2110