Membership Applcation or Member Renewal Form

Walter P. Chrysler Club - 10,000 Lakes Region

Minnesota Chapter (Region) Membership  

Date:______________               Circle:   New application    or     Renewal

                                                                                (PLEASE PRINT LEGIBLY)

YOUR NAME:_________________________________________________

SPOUSE/PARTNER:___________________________________________

STREET ADDRESS: ___________________________________________

CITY, STATE, ZIP: _____________________________________________

PHONE NUMBERS:

HOME:____________________________

CELL:__________________________

BIRTHDAYS:

YOU: MONTH/DAY ____________________   PARTNER: MONTH/DAY_____________________

EMAIL ADDRESS:

YOU: ________________________________  PARTNER:________________________________

*Note: This information will be used in the membership directory, which is received by all club members. It will never be shared outside the club.

Chrysler Vehicles Owned

YEAR          MAKE             MODEL                   BODY STYLE                        COMMENTS

1.______________________________________________________________________________   

2.______________________________________________________________________________

3.______________________________________________________________________________

4.______________________________________________________________________________

More cars? Add them on the back of the page.

APPLICATION or RENEWAL INFORMATION:

Mail this form and a check for $20.00, payable to “WPC 10,000 Lakes Region” to:

Kathryn Oyen, Membership Secretary                     phone #: 612-623-3056

1105 Monroe St. N.E.

Minneapolis, MN 55413

To become a member of the National WPC Club, please go to www.chryslerclub.org for more information.