The Model T Ford Club of Greater St. Louis, Inc.
Membership Application and Renewal Form

Date:  _______________

Name:_________   __________________________ Spouse:________________________ 

Address:__________________________________________________________________  

City:______________________________________________ 

State:______________  Zip:________________ 

Home Phone:___________________ Work Phone:________________  Cell: ______________

Occupation:_____________________________  Email:___________________________ 

Model T’s owned: 
1:________________________________    3. _________________________________ 

2:________________________________    4. _________________________________
May we list your information in the roster for club use only   yes___  no ___

Please check one of the following three boxes:
__  I wish to be a member of the local chapter only. I am enclosing a check for $12.00.  
       Please make check payable to the Model T Ford Club of Greater St. Louis
__  I wish to be a member of both the local chapter and the National. I am enclosing a check for  
      $35, which covers both local and National dues.  Make check payable to MTFCA.
__  I have received a dues notice for National dues and am enclosing it with my check for $35.
      I understand that my local dues are waived because of my National membership. 

For Local Members Only:
Dues run from January through December. Dues paid after October 1st (new members only) cover membership through December of the following year. 

National Members Only: 
Your National due date will be considered your due date with the local club also.
There are several advantages to joining the National:
1) The club's cost for insurance from the National is half price.
2) You receive a year's subscription to Vintage Ford Magazine (a bi-monthly publication otherwise costing $4.00 per issue plus postage), a National windshield sticker, and a membership card.

Send completed Membership Application, along with your dues to:

Jackie Allen
1415 Criterion Ave.
St. Louis, Mo. 63138
314-741-4158

------------------------------------------------------- Club use Only ------------------------------------------

Membership Date Dues Paid ___________  Check # __________      $ Amt. _________
Check sent to MTFCA______________      Check sent to Treasurer ________________