DAIRYLAND REGION PLYMOUTH OWNERS CLUB

                                                                                        Membership Application

Use this form to join the Dairyland Region of the Plymouth Owners Club, Inc. MEMBERSHIP IN THE NATIONAL IS REQUIRED TO BELONG TO ANY REGIONAL BRANCH OF THE POC. While membership in the National does not require any Regional association, it is in the interest of the Plymouth Hobbyist / Enthusiast to enjoy the friendship of others with like interests in his or her area. PLACE AN X IN ONE OF BOXES BELOW:

□ Yes. I want to join the Dairyland Region of the Plymouth Owners Club Inc. I am already a member of the National and have enclosed my check for $20.00 for Regional membership dues.  ($10.00 if after July 1st)  

□ Yes. I want to renew the Dairyland Region and National Plymouth Owners Club Inc. and have enclosed my check for $50.00 covering Regional dues ($20.00) and National Dues ($30.00).

□ Yes. I want to renew only the Dairyland Region membership. National dues have been paid directly and I have enclosed my check for $20.00 covering Regional dues only ($20.00).

□ Yes. I am a First Time Member and want to Join the Dairyland Region and National Plymouth Owners Club Inc. and have enclosed my check for $52.00 covering Regional dues ($20.00) and National dues ($32.00).

Make checks payable to: DAIRYLAND REGION PLYMOUTH OWNERS CLUB and mail to:

Helen Gellert

110 E. Lincoln Highway

Franklin Grove, Illinois 61031-9603

NAME________________    __________________________SPOUSE_____________________

ADDRESS______________________________________________________________________

CITY__________________________________________STATE_______ZIP_________________

HOME PHONE_____________________________CELL_________________________________

EMAIL__________________________________________________________________________

SPOUSE'S EMAIL________________________________________________________________

BIRTHDAY MONTH and DAY_________________  _____  SPOUSE BIRTHDAY MONTH and DAY________________  _____

WEDDING ANNIVERSARY  MONTH and DAY___________________  _____

VEHICLE REGISTRATION INFORMATION

YEAR AND MODEL

1._________________________________________________________________________

2._________________________________________________________________________

3._________________________________________________________________________

4._________________________________________________________________________

Date paid _________________ Check No. ____________ Year Dues Covers ________________ Any questions please contact

Helen Gellert  (815-456-2023) or email DairylandRegionPOC@Yahoo.com