Membership Information Form

Welcome to the Central NY Chapter

PT Cruiser owners Club

The club that supports You !!

First Name: __________________________________________________

Last Name:___________________________________________________

Birthday: ____________Month______________Day

Associate Member; (i.e. Spouse) _________________________________

Birthday: ____________Month______________Day

Address: _____________________________________________________

City:_______________________ State: __________________      Zip: ______

Phone: __________________________________

Email:__________________________________

Year of PT: ______        Model: _____________ Color:____________

No Dues, No Fee, 315-492-9273 for more information

Mail to:

Richard Lang

Central NY Director

PT Cruiser owners Club

4308 Graham Rd

Jamesville, NY 13078

Or copy the form, paste it to new mail and send it to Rlang3@twcny.rr.com