Name:

Spouse/Partner (if Applicable):

Street address:

City:                                                                              State/Province:                Zip:

Phone number:                                                              Cell phone:

Work phone:                                                                  Fax  number:

E-Mail address:

Please list your Classic cars below:
Year          Marque          Cyl          Model/Series          Body Style          Body builder(if custom)

1

2

3

4

Membership dues are $25.00 per year (U S funds); spouse/partner of an active member is $5.00
Regional members must also be National CCCA members, see CCCA membership application.
Mail this application, the questionnaire, and appropriate payment to the UMR CCCA to: