Type info into blanks, then print out form.

Date   

IS THIS A RENEWAL MEMBERSHIP?    YES    NO 

If not a renewal membership, have you ever been a member of this club in the past?  Yes   No   

             If "Yes", when?  


Name:	

Address:

City:	  State: 

ZIP:	               Phone: 

Country:

E-mail address: 



Are you a member of Mustang Club of America (MCA)?   Yes   No   

      If "Yes", what is your MCA membership number?  


Membership is for:   Self   Family  


If family, list names & birthdates:





Type and description of collectible Fords you own:




List any special talents or assets you have available that may be of 

    special benefit to the club (computer, special business or 

    restoration skills)





Interests: (choose any that apply)

Car Showing   Autocross   Open Track   Drag Racing   

Cruising   Restoration   General Interest 



64 1/2-66   67-68   69-70   71-73   74-78   

79-83   84-93   94-98   99- 


Amount enclosed   (dues are $20.00 per year)