Name
______________________________________________Date____________
Address
____________________________________________________________
City
_____________________________ State________ Zip___________________
Home
Phone______________________ Work Phone________________________
Email
Address_______________________________________________________
Associate Member’s Name_____________________________________________
(Please check all that
apply)
Are you a New member ____ or are you Renewing member ____
Events Interest: (Please place a letter H=high, A=Average, L=Low, to show your interests)
|
Concours |
|
Rallying |
|
Social |
|
Technical |
|
Trips |
|
Club Officer |
DeTomaso Automobiles
|
VIN |
Model |
Year |
Color |
License |
State |
Year Acquired |
|
Show |
Race |
Pleasure |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
How
did you learn about EPA? __________________________________________
Annual
dues are $25.00 USD . Please send this application
with your check, made
payable
to Eastern Pantera Association, by March 31, 2008.
Send to: Jay
Curreri
Phone
717-691-1388 or JAYTCREC@aol.com