Membership Form
                                   (January 1 through December 31, 2008)

Your Name: ____________________________________ Birthday ___________________________
         Occupation:  __________________________________________________________________

Spouse's Name: _________________________________ Birthday ____________________________
         Occupation: ___________________________________________________________________

Address: __________________________________________________________________________

City: _____________________________________  State: ______________ Zip: ________________ 

Phone: (____)_________________________  Cell: (_____) __________________________________

Email address: _____________________________________________________________________

Name of Children: (Please list all of your children and birthday.)

1. _____________________________________   Birthday: _______________________________

2. _____________________________________   Birthday: _______________________________

3. _____________________________________   Birthday: _______________________________

4. _____________________________________   Birthday: _______________________________

Club Car(s):
(1)        Year ________________ Make/Model ____________________________________________
(2)        Year ________________ Make/Model ____________________________________________
(3)        Year ________________ Make/Model ____________________________________________

Which Club Activities Would you like to Help Organize?   
Car Shows ________  Cruises ________ Show/Shine ________  Officer _________
Photographer _______  Newsletter _________ Other ___________

Year You joined PVMC ____________  Paid Membership: $20.00 ____________

What is your main reason for joining PVMCC ______________________________________________
_________________________________________________________________________________
Who recommended you? ______________________________________________________________
Date: __________________________

Please Return Membership Form and Dues To:
Platte Valley Mustang Car Club:
C/O Bill Kohler - Treasurer
2005 Keene Drive
Columbus NE 68601
bill.kohler@behlenmfg.com