NORTHLAND CHAPTER MEMBERSHIP APPLICATION

Please complete and print this form, make your check payable to: JON WURM, TREASURER, and mail to:

Jon Wurm, Treasurer
Northland Chapter
6709 Greenway Lane
Forest Lake, MN 55025
Name
Street address
Address (cont.)
City   State/Province
ZIP/Postal code                  Country 
Telephone E-mail 
Professional Car(s) Owned
Year (1968)
Body by (Superior)
Chassis by (Cadillac)
Body Style (Crown Sovereign
3-way hearse)
Membership Dues
Comments
 

*By checking this box, you state that you are a member of the PCS, Inc.

 
 

 *Reminder:  You must be a member of The Professional Car Society, Inc. to join the Northland Chapter.