I.M.C.A. OLD-TIMERS
Please print clearly 2011 NEW/RENEWAL APPLICATION
Name____________________________________________Membership #__________
Spouses Name_______________________ Address_________________________________________
City State Zip
Home Phone______________________Mbl______________________Wk__________________
Email Address____________________________________________________________
Were you formerly associated with I.M.C.A. Yes/No_________________________________
RACE CARS YOU OWN
YEAR BODY STYLE ENGINE CAR CONDITION RUN SHOW
GIVE A BRIEF DESCIPTION OF YOUR CAR(S) THEIR HISTORIES, ETC.
Fiscal Year Jan. 01 – Dec. 31 New and renewal membershipdues :$20.00 FirstTime $10.00
Delinquent renewal dues processed after MARCH. 1, $25.00
MAKE CHECKS PAYABLE TO: I.M.C.A. OLD TIMERS MAIL TO:
John Ellingson
4100 Victoria St
Minnetonka, MN 55345-1963
952.933-3215
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