BCA Membership number _________________
(If not a current BCA member, complete the BCA form
linked at the page bottom and enclose an additional $50.00)             National BCA dues $50.00
Gopher State Chapter dues (pays July 1 through June 30)                Gopher State dues $20.00
Call for our new member special introductory rate!                         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 ___________

   Year           Model Name                         Model # or Type                  Body Style
                     example: Riviera                     example: 4EZ57                  example:  2D coupe
  _______   _____________________   ____________________   ___________________
  _______   _____________________   ____________________   ___________________
  _______   _____________________   ____________________   ___________________
  _______   _____________________   ____________________   ___________________
  _______   _____________________   ____________________   ___________________
Comments or Questions:



How did you hear about our club? ___________________________________________________

Please make your check payable to GSCBCA and mail to: