Michigan Region ~ CCCA
Membership Application*
National Classic Car Club of America requires membership as a condition of Michigan Region membership. (click on www.classiccarclub.org)

Member Name	Spouse Name
Street Address	City or Twsp.
State &  Zip Code	e-mail address
Occupation	Fax Number
Work Phone	Home Phone
Children	Name    Age     Name     Age
	Name    Age     Name     Age
Classic Cars Owned	Year Make Model Body Style Cyl.
	Year Make Model Body Style Cyl.
	Year Make Model Body Style Cyl.
	Year Make Model Body Style Cyl.
	Year Make Model Body Style Cyl.
	Year Make Model Body Style Cyl.
	List additional cars on a separate sheet and send with application
Committee Interests	Activities Publications Carnival of Cars Other
Type of Membership	New       Renewal              Charter
Active Membership - US	($20.00 U.S. funds)
Active Membership - Canada & Foreign	($23.00 U.S. funds)
Associate Membership	($5.00 U.S. funds spouse of active member only)
Total U.S. funds Enclosed
Referring Member (optional)	Today's date
Print and mail completed form with check to:	Nancy Seyfarth Membership Chair, Mich. Region 300 Riverfront Drive PH 2711  Detroit, Michigan 48226
For Staff Use Only	Membership No.  Associate No. New No.