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Print this handy Application for new or renewal, if renewal write name & changes only
BCA Membership number _________________
(If not a current BCA member, also complete the enclosed
BCA membership form and enclose an additional $40.00) National BCA dues $40.00
Gopher State Chapter dues (pays July 1 through June 30) Gopher State dues $20.00*
* New members only, $10.00 if paid after January 1st Total Enclosed $_____
Name ______________________________________ Spouse/partner __________________
Address ____________________________________ Evening phone __________________
City ____________________ State ___ Zip __________ Day phone __________________
e-mail address ___________________________________ Cell phone _________________
Month of your birthday __________ Spouse/partner _________ Anniversary ___________
All Buicks Currently Owned (not necessary for membership)
Year Model Name Model # or Type Body Style
example Riviera example 4EZ57 example 2 D coupe
_______ _____________________ ____________________ ___________________
_______ _____________________ ____________________ ___________________
_______ _____________________ ____________________ ___________________
_______ _____________________ ____________________ ___________________
_______ _____________________ ____________________ ___________________
Comments or Questions:
How did you hear about our club? ______________________________________________
Please make your check payable to GSC-BCA and mail to:
Timothy Bearth - Membership
1328 41st Avenue N E
Columbia Heights, MN 55421-3128
Phone..... 763-788-5758
membership@gopherstatebuick.org
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