I.M.C.A. OLDTIMERS 2012 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 CURRENTLY OWNED:
YEAR BODY STYLE ENGINE CAR CONDITION _______________________________________________________________ ___________________________________________________________
GIVE A BRIEF DESCIPTION OF YOUR CAR(S) THEIR HISTORIES, ETC. _____________________________________________________________ ____________________________________________________________
Events you are able to help or volunteer at:________________________
Fiscal Year Jan. 01 – Dec. 31 membership dues : $20.00
Delinquent renewal dues processed after MARCH. 1, $25.00
First time new members: $10.00
MAKE CHECKS PAYABLE TO: I.M.C.A. OLD TIMERS MAIL TO: Tres. John Ellingson
4100 Victoria St
Minnetonka, MN 55345-1963
952.933-3215
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