(Print, fill out and mail)

Name ______________________________________________                                                                    

Spouse____________________________________________

Address __________________________________________                                                           

City _______________________________________________

State_____________________________Zip______________

Home Phone (_____)________________

Work Phone (____)_________________ Ext.______

Birthdate    ____/_____   Spouse's birthdate        ____/_____

                   MM / DD                                            MM / DD

Email address__________________________________________________________

Shirt size   S__   M__   L__   XL__

Studebaker(s) owned:        Year   Model                                 Year      Model

                                          _____  _____________________     _____    _____________________________    ______     __________________________________  

                                          _____  _____________________     _____    _____________________________    ______     __________________________________

PLEASE INDICATE BELOW IF YOU WOULD LIKE TO VOLUNTEER TO BE ON A COMMITTEE or WANT TO TAKE A PARTICULAR JOB (TRIP COORDINATOR, MAILING LIST, NEWS LETTER STAFF, ETC):

_______________________________________________________________

Signature(s) ______________________________ Date _______________

DUES -  NOTE: You must be a member of the Studebaker Driver’s Club                                                

 $12 per Family  Annually          (Application form for Studebaker Driver's Club is also on this website)                                                

                                                          

PRINT FORM & MAIL WITH CHECK (payable to Los Angeles Studebaker Club) to:            

                                       

        Los Angeles Chapter, Studebaker Driver's Club

        20036 Tuba St.

       Chatsworth, Ca 91311-3444