Damage Inc.
4x4 Club
Membership Application
Please print clearly.
Membership Category
Today’s Date: ___________________
Single ______ $45.00 Membership Fee
Plus $10.00 Initiation Fee For First Year Only.
Family______ $60.00
Membership Fee Plus $15.00 Initiation Fee For First Year Only.
Primary
Member
Name: __________________________________________ Birthday: ______________
Occupation:
____________________ Driver’s License Number ___________________
Address:
________________________________________________________________
City,
State, Zip: __________________________________________________________
Home
Phone: (____)_____-_______ Cell Phone: (____)_____-_______
E-Mail Address:
_________________________________________________________
Phone numbers
and e-mail addresses are for members’ use only.
Referred By: _____________________________________________________________
Joint Member (Leave blank if same as above or if Single membership.)
Name:
______________________________________ Birthday: __________________
Occupation:
____________________ Driver’s License Number ___________________
Address:
________________________________________________________________
City,
State, Zip: __________________________________________________________
Home
Phone: (____)_____-_______ Cell Phone: (____)_____-_______
E-Mail Address:
__________________________________________________________
Year, Model
& Make of Vehicle: ____________________________________________
How
Long Owned: _______________________________________________________
Are
you a member of another club: (Yes) (No). If yes, which club:__________________
Damage
Inc. Official Use Only:
Member #: ________ Received: ( ) By-Laws, (
) Certificate, ( ) ID Card, ( ) Decal
Initiation Fee Paid ___/___/____
( ) cash ( ) check _____
Record of Dues ___/___/____ ( ) cash ( ) check
_____
Record of Dues ___/___/____ ( ) cash ( ) check _____
Record of
Dues ___/___/____ ( ) cash ( ) check _____
Record of Dues ___/___/____
( ) cash ( ) check _____
Record of Dues ___/___/____ ( ) cash ( ) check
_____