Middle Peninsula Mopar Association Application

Your Information:
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: ___________________

List Mopar's Owned (Please use back of this application if more room is needed)

YEAR	MAKE	MODEL	ENGINE	COLOR

How did you hear about the Club? ___________________________________________

ITEM	DESCRIPTION	SIZE IN STOCK	QTY	COST	TOTAL PRICE
1 Year Family MPMA Membership	Membership entitles you to 1 year Membership to MPMA. All dues expire 12/31 of each year.	n/a	1	$20.00
4th Annual Guinea Jubilee t-shirt	White - Harley Davidson Theme	Small Medium Large XLarge 2XLarge 3XLarge		$10.00 ea.
Shipping & Handling					FREE
Total

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

Please Send Check or Money Order of The Total Amount From Above Payable & Mail To:
Middle Peninsula Mopar Association
PO Box 1734
Hayes, VA 23072