454SS North American Truck Club

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

PO Box 267

Remington, Indiana

47977

Please make Checks Payable To Eric Barber