Please print this out and fill it in and send it to: 

EDMONTON MOPAR CLUB   

4308 -73 St. 

Edmonton AB, T6K 0V7

 

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: ________________________________________________________________________________________________________________________

Membership includes: Newsletters, Club window decal, Membership card and free ads in the Newsletter.

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.
 
 ----------------------------------------    --------------------------------------
                            Signature                       Date                                 

Executive Use Only:  Membership Fee: $30.00/ yr.

Method of payment: ___________ Date rec.: ______________

Decal issued: _________ Membership card: ____________

Member #: __________

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