Membership Application

 

LastName:___________________________ E-Mail: ____________________________

 

FirstName:___________________________ City: ______________________________

 

Spouse: ______________________________ Occupation: ________________________

 

Address: ________________________________________________________________

 

City:_________________________________ State: _______ Zip: ___________________

Home Phone:__________________________ Work Phone:_________________________

 

For renewals please specify your existing membership number (if known) _________________

 

You may list up to 4 Model T’s that you own:

Car 1: ________________________________Car 2:______________________________

 

Car 3:_________________________________Car 4: _____________________________

Note: We normally include membership information on our club roster which is never sold or used for non club purposes. 
You may still request that we not put your information in the printed roster by clicking the checkbox below.

Do not include my information in the club roster

1 Year Individual or Family Membership

U.S.………………………………….$35.00

Foreign Countries……………………..$40.00

(In US funds drawn on a U.S. Bank)

Individual Life Membership….....………$600.00/$700 Intl

 

Make checks payable to:

Model T Ford Club International

Mail to:

  M.T.F.C.I. PO Box 355

 Hudson, N.C. 28638-0355

 

Please enter the following information if you would prefer to use VISA or MasterCard:

Please bill my VISA or MasterCard for ______________ (amount)

 

                                              Card Number: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __

 

Expiration Date: ____________  Signature ___________________________________