Membership Application
___$35 Yearly membership includes one logo embroidered polo shirt, one logo window decal & free ads in the newsletter!
___$35 Yearly membership includes one logo printed t-shirt, key chain, window decal & free ads!
___$55 Family (must live in same household) membership includes 2 logo embroidered polo shirts, 2 logo window
decals & free ads!
___$55 Family membership includes two logo printed t-shirts, 2 key chains, 2 window decals & free ads!
___$60 Family membership includes one logo embroidered polo shirt, one logo printed t-shirt, 2 key chains, 2 window decals & free ads!
Name __________________________________________________________________________________________
Address ________________________________________________________________________________________
City ______________________________________________ State __________________ Zip _________________
Spouse/Family Member Name ____________________________________________________________________
Home Phone (_________) __________-_____________ Shirt Size _________________(XXL add $2 extra per shirt)
E-Mail Address __________________________________________________________________________________
Do you object to your name, address or car information being listed on our roster or newsletter? Yes___ No___
Do you prefer that the monthly newsletter be sent via: Email_____ US Mail_____
Year Make Model Body
1) ____________________________________________________________________________________________
2) ____________________________________________________________________________________________
(may list additional vehicles on back of page)
How did you find out about our club? _______________________________________________________________
Additional items available to purchase with our logo on them:
Hat $ 10.00
Sweatshirt $19 .00 (XXL add $2.50 extra per shirt)
Polo Shirt $ 17.00 (XXL add $2.00 extra per shirt)
T-Shirt $ 13.00 (XXL add $2.00 extra per shirt)
Men's Tanks (Muscle Shirts) $11.00 (XXL add $2.00 extra per shirt)
Youth T-Shirts (2-4, 6-8, 10-12, 14-16) $12.50
Window Decal $ 7.00
Key Chain $10.00
Cast Aluminum License Plate $30.00
The club is only for Chrysler made vehicles and must be powered by a Chrysler engine.........they DO NOT have to be
Antiques or Classics, they can be of any year!!
Make checks payable to: SCIMC and mail to:
South Central Indiana Mopar Club
Attn: Chris or Suzi Pointer
4625 Stansbury Place
Spencer, IN 47460
Our website address is: www.oocities.org/scimoparclub Not yet fully completed- - -UPDATES REGULARLY!
For more info, you may call (812) 935-8704 or email us at spointer@indiana.edu or scimoparclub@yahoo.com
to the address listed on the application. You can also email us at either above email
address to have an application sent to you thru the US mail or via an email. Thanks!