Name   

Address:

City:           State:    Zip: 

Telephone:    Date:

Email Address:

(optional)

Member's Birthday (Month/Day):

Spouse's Name:   

Spouse's Birthday (Month/Day):  

Wedding Anniversary:  

Children (unmarried, under 21):

    Name                                                                          Birthday (Month/Day/Year)

List Your Antique & Classic Cars

    Year               Make & Model

Name of Insurance Carrier

I wish to become a member of the Ben Hur Car Club.  I promise I will (1) Abide by the bylaws of this club; (2) Assist on committees when asked to do so; (3) Participate in club activities; (4) Uphold purposes of the club in the interest and/or acquisition of antique and classic cars, literature and related subjects.  I understand that the Ben Hur Car Club is a non-profit club.

____________________________________________

(Signature of Applicant)

For use by club Treasurer:

Dues Paid $ _______  For Year _______ Signed __________________________ 

                                                                                                 (Treasurer)

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