Membership Application

Dear Prospective SCCA Member:

To apply for membership in the Sports Car Club of America, the world's largest membership participation automotive organization, please complete the form below in full and return, with payment, to yoru region or the SCCA Memebership Department, P.O. Box 19400, Topeka, KS  66619-0400.

PLEASE PRINT OR TYPE

Name ________________________________________________________________ Birthdate _________/_________/________

Address ___________________________________________________ Telephone (________) ___________________________

City _____________________________________________ State_______ Zip_____________ Country _____________________

E-mail ___________________________________________________________________________________________________

_____ Single  _____ Married Spouse's Name _________________________________ Birthdate ________/_________/_________

Spouse Member Number If Current Member _______________________________________

IF APPLYING FOR FAMILY MEMBERSHIP(husband/wife and children), list names and ages of children under age 21:

03 Name ______________________________________________________________ Birthdate ________/________/_________

04 Name ______________________________________________________________ Birthdate ________/________/_________

05 Name ______________________________________________________________ Birthdate ________/________/_________

06 Name ______________________________________________________________ Birthdate ________/________/_________

Have you been an SCCA member before _____ No ______ Yes Year _______ Previous Member No. _______________________

PRIMARY INTEREST(S) IN SCCA:

Please indicate the area(s) of SCCA in which you plan to participate, or which interest you most.  Your response will be used to allocate your national dues to the areas you indicate.  Thank you.

_____ Club Racing        _____ Pro Racing        _____ ProRally        _____ RoadRally        _____ Solo            National Office Use Only

                                                                                                                                                                            ______________________

                Annual National Dues                        Annual Regional Dues                            Total                      

01 ___ Regular Member                      $55.00  +    Regular Member            $15.00    =            $ 70.00              C- _______ $ ___________

03 ___ Spouse Member                      $15.00  +    Spouse Member            $  5.00    =            $ 20.00              C- _______ $ ___________

10 ___ Family Membership                  $85.00  +    Family Membership        $15.00    =           $100.00              C- _______ $ ___________

    ___ First Gear(must be under 21)   $30.00  +    First Gear (Reg. Dues) $15.00    =            $ 45.00                             Source _D_

_____ Enclosed is my check or money order for $________________________________________________ U.S. DO NOT SEND CASH.

_____ VISA    _____ MC        No. ______________________________________________ Expiration Date ___________________

  I hereby apply for membership in the Sports Car Club of America, Inc. and its SOWELA/44 Region and agree to abide by the bylaws.

Applicant's Signature ___________________________________________________ Date ________________________________