NORTHWEST NOMAD ASSOC., INC.

APPLICATION FOR MEMBERSHIP  

 

APPLICANT’S NAME _____________________________________________________________________________

RESIDENCE _____________________________________________________________________________________

MAILING ADDRESS ( if different) _________________________________________________________________

HOME PHONE ______________________ BUSINESS PHONE_______________________

DATE OF BIRTH _______ OCCUPATION ___________________________ WED. ANNIV. DATE ________

CO-APPLICANT’S DATE OF BIRTH ___________ OCCUPATION ___________________________________

NOMAD YEAR ___________ COLOR _____________ STOCK _____ CUSTOM ____ ENGINE ____________

IF YOU BELONG TO ANY OTHER CLUBS, PLEASE LIST NAMES :   _________________________________

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DUES FOR THE NW NOMAD ASSOCIATION, INC. ARE $12 PER YEAR FOR A FAMILY MEMBERSHIP AND ARE DUE APRIL 1st EACH YEAR. IF YOU ARE JOINING IN ANY OTHER MONTH – JUST MULTIPLY $2 TIMES MONTHS LEFT UNTIL APRIL.

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DATE OF APPLICATION

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SIGNATURE OF APPLICANT

EACH MEMBERSHIP APPLICATION MUST BE SUBMITTED TO THE SECRETARY OF THE NORTHWEST NOMAD ASSOCIATION, INC.

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(PLEASE DO NOT WRITE BELOW THIS LINE)

APPLICATION RECEIVED ___________________________________________________

APPLICATION APPROVED BY BOARD ________________________________________

DUES FORWARD TO TREASURER ____________________________________________

SECRETARY’S ADDRESS: MARLENE MILLER, BOX 251, BORING OR 97009