| MEMBERSHIP APPLICATION Annual Dues: $20.00 |
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Name: _______________________________________________ |
POCI #: ___________ |
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Address: _____________________________________________ |
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City : __________________________________ State: _______ |
ZIP: _____________ |
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Phone: ________________________________ |
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email: _______________________________________________ |
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PONTIAC/OAKLAND/GMC VEHICLES OWNED: |
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| YR:______ |
Model: ____________________________________________ |
Engine: ___________ |
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| YR:______ |
Model: ____________________________________________ |
Engine: ___________ |
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| YR:______ |
Model: ____________________________________________ |
Engine: ___________ |
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| YR:______ |
Model: ____________________________________________ |
Engine: ___________ |
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Make checks payable to: Illinois Chapter POCI |
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Mail to: Illinois POCI
15456 Scott Ct.
Lockport, IL 60441 |
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Note: We publish a club roster that is distributed to Illinois Chapter members.
If you do not want some or all of the information above published in the
roster, place an X next to the information you do not want published |
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Do not publish: ___ Name ___ Address ___ Phone ___ Cars Owned ___ email
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