THE FURRIN GROUP

Name:    _______________________________________ Date: ______________________
         please print

Spouse:  _______________________________________
         please print

Address: ____________________________________________________________________
         street                          city           state          zip

Phone:   _(____)_____________________  E-mail: ______________________________

Place of Business:  _________________________________________________________
                    please print

Phone:              _(___)_______________

Email Address:      ________________________________________________________

Cars:
Make: _________________________  Model: __________________  Year: ___________

Make: _________________________  Model: __________________  Year: ___________

Make: _________________________  Model: __________________  Year: ___________


Interests In Furrin Group: ( Rallies, Ice Events, Speed Events, etc )
                           ( please list in order of preference below)

_____________________________________________________________________________

List Memberships in Other Sports Car Clubs:

_____________________________________________________________________________

Sponsor Signature: ________________________________________


Dues:  $17.00  Single     Please Submit Application to: Membership Chairperson
       $27.00  Family                                   Furrin Group
                                                        P.O. Box 1665
Amt. Paid  __________________                           Grand Rapids, MI 49501

Office Use Only Below this point

Membership Chair ______    Mailing/Journal Chair ________ Treasurer __________ Points Chair_____