This is a copy of application form:
2005 VIPER CLUB OF AMERICA MEMBERSHIP APPLICATION
Questions? Call Viper Headquarters toll-free at 1-800-998-1110
CURRENT VCA # (if available) ______________________________________________
NAME: _________________________________________________________________
FIRST MIDDLE LAST
2nd BADGE NAME (if applicable):_____________________________________________
FIRST MIDDLE LAST
ADDRESS: ______________________________________________________________
CITY: __________________________STATE: ________ ZIP CODE: _________-______
DAY PHONE NUMBER: (______)_______________ E-MAIL: ______________________
VIPER VIN NUMBER: _____________________________________________________
COLOR: _________________ YEAR: _____________ MODEL: _______________
DID YOU PURCHASE YOUR VEHICLE NEW OR USED
(PLEASE CHECK THE APPROPRIATE BOX)
LOCAL CLUB SELECTION
**IMPORTANT**—THIS SECTION MUST BE COMPLETED OR YOU WILL AUTOMATICALLY BE ASSIGNED TO A REGIONAL CLUB BASED ON YOUR GEOGRAPHIC LOCATION.
My regional club selection is: __________________________________
Club name selected from list below
Please choose one of the following and indicate above:
4 Alabama/Tennessee 4Arizona 4Carolina 4 Central California 4Central & Northern Florida 4Colorado
4Gateway (Missouri, Eastern Mississippi, Southern Illinois) 4 Georgia 4Houston 4 Illinois 4Indiana/Kentucky
4Kansas City 4 Mid-South (AR/LA/MS) 4Minnesota 4Motor City 4Nebraska/Iowa 4Nevada 4New England
4New Jersey 4New Mexico 4New York/Connecticut 4 Northern California 4North Texas
4Ohio 4Oklahoma 4Oregon 4 Southern California 4South Central Texas 4 South Florida 4Virginia/Maryland
4 Washington 4W. Virginia/Penn.
Two response options! For your convenience and fastest service, please fax the completed membership application to Viper Headquarters at 1-248-553-2138. If you prefer, please mail a check or money order payable to Viper Club of America.
PLEASE SELECT METHOD OF PAYMENT MAKE CHECKS PAYABLE TO THE VIPER CLUB OF AMERICA
VISA o MASTERCARD o CHECK o MONEY ORDER o
Credit Card #: __________________________________________________________________________
Expiration Date: ______/______ Name on card (PLEASE PRINT): _________________________________
Signature: ______________________________________________________________________
Please take a moment to complete this short member survey:
Would you like to plan a club event? ______Yes _______ No
What type of an event? _________________________________________________________
Are you involved with any other car clubs? If so, which club(s)?_________________________
____________________________________________________________________________
Please indicate your interest in these events: (1=Very interested) (2=Moderate interest) (3=Not interested)
Driving tours ______ Autocrosses ______ Dinners/lunches ______ Road Races ______
Other (specify) ______ Car Shows ______ Drag Races ______ Car Parades ______
Events/drives with overnight stays ______ Driving Schools at race tracks ______
At some point, would you consider being an officer of the Club? _________
If so, what positions? 1.__________________________ 2._____________________ 3._________________
Membership Liability Waiver: “In consideration of the right of membership by execution of this membership form, I release and discharge DaimlerChrysler Corporation, its divisions and subsidiaries, the Viper Club of America, Inc. and its Regions, officers, agents, members, representatives, and all others persons or Agencies affiliated with this Club from any and all known and unknown damages, injuries, judgments, and/or claims from any cause whatsoever that may be suffered by me or any member to his/her person, family or property and related to your membership or participation in this Club.”
Cudaman
Signature: _________________________________________________ Date:_______________________
