Membership Application for Model "A" Ford Club of America, Bakersfield Chapter, Inc.
Post Office Box 1616, Bakersfield, CA 93302
Please print this form, fill it out and mail it to the above address together with your $25- fee.
(prorate $2- per month).

Name of Husband: __________________________________ Date of Birth: ___/___/___/

Name of Spouse: ___________________________________ Date of Birth: ___/___/___/

Mailing Address: _________________________________________________________

Telephone: _____-_____-______  Email: ______________________________________

Children (children under the age of 18 are included in a family membership)

    Name: _________________________________________ Date of Birth: ___/___/___/

    Name: _________________________________________ Date of Birth: ___/___/___/

    Name: _________________________________________ Date of Birth: ___/___/___/

    Name: _________________________________________ Date of Birth: ___/___/___/

Date of Wedding Anniversary: ___/___/___/

List the following information (not required for membership)

    Year of Model "A":         Body Style:                                                                           

    ____________________________________________________________________

    ____________________________________________________________________

    ____________________________________________________________________

    ____________________________________________________________________

List any activity that you want the club to participate in:
______________________________________________________________________

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