New Member Application

MIATA CLUB OF MINNESOTA

 P.O. Box 385554

Bloomington, MN 55438

 

If you have any questions contact the Club Secretary at Secretary@MiataClubMN.com or one of the club officers at www.miataclubmn.com/clubinfo/boardmembers_page.htm

 

 

 

NAME:

 

CAR YEAR:

 

ADDRESS:

 

CAR COLOR:

 

CITY/STATE/ZIP:

 

LICENSE NO:

 

E-MAIL:

 

HOME PHONE:

 

CELL PHONE:

 

WORK PHONE:

 

 

YES      NO      LIST MY NAME IN DIRECTORY

YES      NO      LIST MY ADDRESS IN DIRECTORY

YES      NO      LIST MY PHONE NUMBERS IN DIRECTORY

YES      NO      LIST MY E-MAIL ADDRESS

 

Total Amount Due

 

First Year Dues and Entry Packet ($50.00 + $5.00 S/H) = $50.00                           $55.00___________

                 Size:  M  L  XL XXL  T-Shirt (Included)                            _NC_____________

                 Size:  M  L  XL XXL  T-Shirt (Extra -- $15.00)                

TOTAL ENCLOSED . . . . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . .  . . . . . . .  

In order to speed timing on events, please sign the following form so we can have it on file for your current year of membership.  Thank you.

 

EVENT RELEASE FORM

 

I agree not to hold the Miata Club of Minnesota or its officers liable (personally and professionally) for any accident/damage that may occur to me or my auto during events. I accept full responsibility for my actions.  If I have an accident/damage, I agree to settle the dispute only with the individual person directly involved in the accident/damage. The Miata Club and its officers accept no responsibility either personal or professional for any accident/damage that might occur during the current membership period.

 

Date of Membership:    thru

Name(s):

 

 

                                                                                                                                       

 

                                                                                                                                      

                          Signature(s):  if appropriate, both sign please