Midwest Chapter - Model T Ford Club International

Application for Membership (Internet)
(Subject to approval of Board of Directors)

Date Of Application___________

Name___________________________________ Birthday___________
(First) (Middle) (Last)

Spouse's Name____________________________ Birthday___________

Address_______________________________________Apt.____________________

City________________________________State____________Zip___________

Home Phone(____)___________Business Phone(____)______

Wedding Anniversary Date___________

Occupation___________________________________________

Current Member Of The Model T Ford Club International?______
If So; Membership #___________ Expiration Date________

Antique Cars Owned
(List of Members and Antique Cars is included in our Annual Roster)
Year Make Model Body Style Condition* Engine Number
_______ __________ __________ ______________ __________ __________
_______ __________ __________ ______________ __________ __________
_______ __________ __________ ______________ __________ __________
_______ __________ __________ ______________ __________ __________
_______ __________ __________ ______________ __________ __________
* Conditions: "U"-Unrestored, "P"-Partially Restored, "R"-Restored, "O"-Original


Children (Under 16 Years Old)
Name Age
___________________________________ ________
___________________________________ ________
___________________________________ ________
___________________________________ ________


Payment Enclosed $__________
(Payable to the Midwest Chapter, Model "T" Ford Club)

Mail to:
The Midwest Chapter Model T Ford Club International
Bob Solak
Membership Secretary
151 Kenilworth
Glen Ellyn, IL 60137


Applicants Signature___________________________________


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