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					                                    Willamette Valley Miata Club

                                Membership Application
________________________________________________________________________

Print this page, fill it out and mail to:

WVMC
P.O. Box 20612
Keizer, OR 97307

MEMBERSHIP APPLICATION
1st year dues are $30.00 this includes the associate member, Renewals are $20.00 per year.
You will receive a WVMC name badge, WVMC car window sticker and full access to our club website.

Primary Members Name: (Please print your name as you would like it to appear on your Club I.D. badge).

_______________________________________________________________________________
Associate members name (ie. spouse):

_______________________________________________________________________________

Year of Miata_______________ Color of Miata_________________________
Got more than one Miata?

Year of 2nd Miata____________ Color_________________________________

Address______________________________________

City_________________________ State _____________Zip ________________

Email address___________________________________

Telephone #____/_________________

Cell Phone ______________________

Do you have current insurance? _______ YES _______ NO

Insurance Company Name: ____________________________________

 Check here if you do not want your information listed in the club directory

				
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posted:8/31/2011
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