Membership Application

Last Name, First_______________________________Spouse_______________ Age(s) His __________  DOB _______________ Hers __________ Address ___________________________________________  City_____ State______Zip_________ Preferred telephone # ____________________________     Home, Work or Cell Alternate telephone # ____________________________     Home, Work or Cell Email address _____________________________________________________ Club Car Information: Car #1 _____________________________________________________________________________________ Car #2 _____________________________________________________________________________________ Car #3 _____________________________________________________________________________________ Special Interest or abilities, for example: Swap meets, Shows, Cruises, etc.

Would you be interested in a committee or officer Position? Y     N

How did you hear about the club? ______________________________

Membership entitles you to 12 issues of the club newsletter, notification of auto shows and swap meets, parts availability information and access to the HMCC's Reference Library, plus meeting a lot of nice Mopar people! Club meetings are usually the second Sunday of each month. Annual membership renewal fee is $20.00 per family. I hereby relieve the Houston Mopar Connection Club, HMCC Inc., its officers and members of all potential liability for any possible harm to my property or for personal injury which may occur while taking part in any club event or any club meeting. I understand that I must be of legal age, be a Mopar enthusiast, and that my membership is subject to approval of the elected officers. HMCC is not affiliated or associated with Chrysler Group LLC or any of its subsidiaries in any way shape or form.

__________________________________________    _________________________________________ Applicant's Signature and Date                                    Spouse's Signature and Date

Make checks payable to: Houston Mopar Connection Club or charge your membrship. IMPORTANT: Below please put an X next to the method you used to pay:                                     CHECK or MONEY ORDER____                                     CHARGE____

Mail to: Houston Mopar Connection Club            c/o Alan Bauer, Membership Director                  13806 Swan Hollow Lane,                  Houston, TX 77041 or send this application by an e-mail.

V: 9-26-2011