THE MG CAR CLUB, WESTERN NY CENTRE, INC.

Please print this 1 page form and mail it with payment to the address at the bottom

Annual Membership Dues are $30.00 -- All Memberships expire December 31st

Name__________________________________________    Birthday________________

Spouse_____________________  Friend_____________________________  Birthday____________

Phone: Home_____________________  Work______________________     Anniversary______________

Address_________________________________________________City__________________________

State__________  Zip+4_____________  Today’s Date____________    New or Renewal?___________

Cars Owned & Yr. _______________________________________________________________________

______________________________________________________________________________________

INTERESTS: Racing____________Gymkhana____________Rallye____________Restoration___________

Hobbies, etc.____________________________________________________________________________

Occupation_______________________      E-mail Address____________________________

Roadside Help? No_______Yes_______>Days_________Evenings______Nights_______Weekends______

MAIL APPLICATION WITH CHECK PAYABLE TO: MGCC OF WESTERN NY, INC. TO:

Jim Priestley
3326 County Road 40
Bloomfield, NY 14469-9224