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Emerald Empire Vintage Auto Club Renewal and Application Membership
NAME_______________________________ SPOUSE__________________________________ ADDRESS______________________________________________________________ CITY_________________________________ STATE________ ZIP+4_____________________ OCCUPATION________________________SPOUSE’S________________________ HOME Ph____________________________ WORK Ph________________________ CELL Ph_________________________ e-mail________________________________ BIRTHDAY______________________ SPOUSE’S B-Day_______________________ ANNIVERSARY Date______________________________ (Year Optional) Vintage Cars Owned (1928 Through 1948) _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Insurance Company_______________________ Policy #________________________
ARE YOU WILLING TO: SPOUSE: Hold An Office YES____ NO_____ YES_____ NO_____ Chair A Committee YES____ NO_____ YES_____ NO_____ Work On A Committee YES____ NO_____ YES_____ NO_____ Participate In Club Activities YES____ NO_____ YES_____ NO_____
SIGNATURE____________________________ Date___________________________ Please Include Yearly Dues Of $20.00 (May Prorate) Send To: EEVAC PO Box 40191, Eugene, OR, 97404
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