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

EDMONTON MOPAR CLUB

#97-21252 TWP 540 Ardrossan,AlbertaT8G 2A2

 

 

 

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: __________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Executive Use Only Membership Fee: $20.00/ yr.

Method of payment: ___________ Date rec.: ______________

Decal issued: _________ Membership card: ____________

Member #: __________

Membership includes: 4 Newsletters, Club window decal, Membership card and free ads in the Newsletter.

 

 

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