P.O. Box 555 * Midlothian, Va. 23113-0555 * 804 276-7460
Name: ___________________________ Occupation: __________________________
Address: _______________________________________________________________
_______________________________________________________________________
Email Address: _________________________________________________________
Release Member Information? Yes ___ No ___
Home Phone: ______________________ Cell Phone: _______________________
Additional Member: ________________ Total $ Enclosed: _____________________
How Did You Hear About The Club? ______________________________________
Current or Past Member of other Motor Sport Club(s)? If so, Please List.
_______________________________________________________________________
Miata Body Color: __________ Year: __________ License Number: _____________
VIN: ____________________________ Accessories package: ___________________
Modifications: __________________________________________________________
Purchased From: ________________________________________________________
The Central Virginia MIATA Club promotes an active membership. Please circle each of the interest below that you would be willing to support with your time:
Rallies & Autocrosses, Discounts, Maintenance & Repairs, Social Activities, Newsletter, Aftermarket Products, Other ______________________________
Signature: ___________________________ Date: ________________________
Last Updated February 21, 2005