MINUTEMAN CHAPTER OF B.C.A.

APPLICATION FOR MEMBERSHIP
please print this page from the web

DATE OF APPLICATION________________

PLEASE TYPE OR PRINT CLEARLY

NAME (S) ____________________________________

ADDRESS________________________________________

CITY, STATE AND NINE DIGIT ZIP______________________________________

AREA CODE AND TELEPHONE_______-______-_________________

YOUR EMAIL ADDRESS_________________@________________

WHEN LISTING YOUR COLLECTOR CARS, PLEASE LIST YOUR BUICKS FIRST.
PLEASE INDICATE THE CONDITION OF YOUR CAR(S). WE USE THE FOLLOWING CONDITION CODE:

A ALL DONE, UP AND ABOUT, LICENSED, ETC.

B COMPLETE, BUT UNLICENSED

C UNDER RESTORATION IN ONE FORM OR ANOTHER

D PARTS CAR (OR CLOSE TO IT)

YEAR EXACT BODY STYLE AND MODEL NAME CONDITION

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YOUR BIRTHDAY___________YOUR PARTNER'S BIRTHDAY___________

YOUR ANNIVERSARY mo._______day_________year__________

YOUR BCA MEMBERSHIP NUMBER AND EXPIRATION DATE_________________________
** membership in the BCA is a prerequisite for membership in our chapter **
but you can join us and then IMMEDIATELY join the BCA

OUR DUES ARE $20. PER YEAR.

Please make check payable to "Minuteman Chapter, BCA"

and SEND CHECK TO:

AL DANN

MINUTEMAN CHAPTER, BCA

194 OXBOW ROAD

WAYLAND, MA 01778
. ____________________________________________________________________________

www office use only MMC-
DATE RECEIVED-
EXP DATE-

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