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454SS North American Truck Club

www.454SS.com

 

 

Membership Application

 

 

Personal Information

 

First Name: _________________________    Last Name: _______________________________

                                                                       

Address: ______________________________________________________________________

 

City: ________________________________  State: ___________________________________

 

 Zip: _________________________________ Country: ________________________________

 

Home Phone: _________________________  Work Phone: _____________________________

 

E-Mail Address: ________________________

Web Page URL: ________________________

 

 

T-Shirt Size (Choose One: )

 

Small _____ Medium _____ Large _____ X-Large _____

 

 

Truck Information

 

Year Manufactured: _____________________________ Color: __________________________

 

Mileage: ________________________

                  

Truck Modifications:

                                                                      

Wheels (Brand): _____________________________  Tires: _____________________________

 

Body Modifications: _____________________________________________________________

 

Engine Modifications: ____________________________________________________________

 

Other: ________________________________________________________________________

 

Send Application To:

 

Eric Barber

C/O 454SS North American Truck Club

835 E 725 N

West Lafayette, Indiana

47906

Please make Checks Payable To Eric Barber