Please print
out form, then complete & send with remittance to.
Wendy Palmer, Membership Officer- Chrysler Owners Club of Qld
Inc
31-37 Bamboo Drive Cedar Vale 4285
CHRYSLER OWNERS CLUB OF
QUEENSLAND INC.
APPLICATION FOR MEMBERSHIP
Please indicate type of membership sought by circling
below:-
SINGLE MEMBERSHIP The member only has voting
rights within the club. However the members family and friends may still
accompany him/her to club meetings and are welcome at club functions.
FAMILY MEMBERSHIP The member and other nominated
family members have voting rights within the club. This covers the family
who has more than one Chrysler product and each person is then entitled
to a part in the decision making process within the club.
| POST (ZIP) CODE : |
State: |
Country: |
PHONE NO.
DETAILS OF VEHICLE/S (If more than one vehicle please
attach list):-
| YEAR OF MANUFACTURE:- |
MAKE:- |
| MODEL: |
BODY STYLE: |
REGN NO: |
| Engine and Drivetrain details:- |
Enclosed is a cheque/money order for $35.00 AUD (Single Membership)
or $50.00 AUD (Family Membership) made payable to CHRYSLER OWNERS CLUB OF
QUEENSLAND INC. with this application.
Please add $10 if applying from
outside Australia.
10/02
OFFICE USE ONLY
| Proposed By: |
Seconded By: |
Date Joined /
/ |
Membership No: |
| Type of Membership SINGLE /FAMILY |
Receipt No: |