REGION RENEWAL FORM - Pay by check

Annual fee of: $25.00 (U.S. funds)

The completed form and annual fee, as established by the Board, shall be due on January 31st of each year. Failure to submit the renewal form may result in being dropped as a region.
Instructions:

All * fields need to be filled in. If information is not available type NA.
ALL REGION MEMBERS MUST BE CURRENT MARC MEMBERS
REGION NAME*
In what U.S. state or country is your region located?*
Number of members in your region*
What is the primary city where you meet.*
Region Contact Person

(Anyone you choose. Their information will appear in the Model "A" News and website):
Membership #*
e mail*
example@example.com
Name (Region Contact Person)*

First NameLast Name
Address*
City*
State*
Zip*
Phone*
President or Director
Membership #*
e mail*
example@example.com
Name (President or Director )*

First NameLast Name
Address*
City*
State*
Zip*
Phone*
Vice President
Membership #*
e mail*
example@example.com
Name (Vice President)*

First NameLast Name
Address*
City*
State*
Zip*
Phone*
Secretary
Membership #*
e mail*
example@example.com
Name (Secretary)*

First NameLast Name
Address*
City*
State*
Zip*
Phone*
Treasurer
Membership #*
e mail*
example@example.com
Name (Treasurer)*

First NameLast Name
Address*
City*
State*
Zip*
Phone*
Additional Board Member
Title
Membership #
e mail
example@example.com
Name (Additional Board Member)

First NameLast Name
Address
City
State
Zip
Phone
Name of your region newsletter*
Editor of your newsletter
Membership #*
e mail*
example@example.com
Name (Editor)*

First NameLast Name
Address*
City*
State*
Zip*
Phone*
PLEASE FILL OUT FORM COMPLETELY

Region Form is due by January 31

Make check out to:

Model A Restorers Club

Mail to:
P.O. Box 498
Howell, Michigan 48844

Please write complete region name on check.

Annual fee of: $25.00 (U.S. funds)
Should be Empty:

ALL REGION MEMBERS MUST BE CURRENT MARC MEMBERS