Date:  

Name:  

Mailing address:  

City, state, zip code:  

Home telephone:  

Work telephone:  

Cell phone:  

Email:  

Sponse's name:  

Number and ages of children:  

Your birthday:  

Spouse's birthday:  

Your wedding anniversary:  

Your Nat'l Street Rod Assoc number (if any):  

Do you own a street rod?  Yes  No

Do you own a street cruiser?  Yes  No

If you own a rod or cruiser, describe it here:  

Are you a member of another street rod club?  Yes   No

If so, which one?  

Are you willing to participate in club activities?  Yes  No