Central Iowa Model A Club

          Application for Membership / Renewal

 Name ___________________________________ 

 Birthday (MM/DD) __________

 Spouse’s Name ___________________________

 Birthday (MM/DD) __________

 Street Address _____________________________________

 City ___________________________________

 State ______________                 Zip ________________

 Phone # ___________________________________

 E-Mail  ___________________________________________________

 Deliver my Newsletter (Check One);  In Color via E-Mail ____  

                                                   Black and White via Mail ____

 Model A’s Owned _______________________________________________

 Other Antique Cars Owned _______________________________________

 Please print and mail this form along with dues of $25 for the year to:

     Central Iowa Model A Club

     P.O. Box 259

     Des Moines, Iowa 50301 - 0259