New Member Application

MIATA CLUB OF MINNESOTA

 P.O. Box 16221

Minneapolis, MN 55416-0221

 

If you have any questions contact Mike Ferber, Club Secretary  651-454-3066 or mgferber@usfamily.net

 

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

 

Total Amount Due

 

First Year Dues and Entry Packet ($42.00 + $3.00 postage) = $45.00       $45.00___________

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

                 Size:  M  L  XL XXL  T-Shirt (Extra -- $12.00) 

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