Please complete the following information
and mail Application plus your $20 annual club dues to the address
below!
Last Name: _________________________ First
Name: __________________________
Address: ________________________________________________________________
City: __________________________ State: ________________ Zip:
_______________
Primary Phone #: __________________________ Cell Phone #: ___________________
Email Address: ___________________________________________________________
Date of Birth: ___________________
Spouse Information
Last Name: ________________________ First
Name: ___________________________
Date of Birth: ___________________ Anniversary Date: _________________________
List Mopar's Owned (YEAR MAKE MODEL ENGINE
COLOR etc.)
How did you hear about the Club? ___________________________________________
Membership entitles you to 12 issues
of the club newsletter, notification of auto shows & swap
meets, parts availability information, plus meeting a lot of nice
Mopar people. Annual membership renewal fee is $20.00 per person.
Dues are good through 12/31 of each year. By signing below I hereby
relieve this Mopar Club, its officers and members of all potential
liability for any possible harm to my property or for personal
injury, which may occur while taking part in any club event or
any club meeting. I understand that I must be of legal age, be
a Mopar enthusiast, and that my membership is subject to approval
of the elected officers. This Mopar Club is not affiliated or
associated with DaimlerChrysler or any of its subsidiaries in
any way shape or form.
_____________________________
Applicant's Signature & Date
Make $20 Checks or Money Order Payable
To: Middle Peninsula Mopar Association
Mail To:
Middle Peninsula Mopar Association
PO Box 1734
Hayes, VA 23072