Membership Application
Dallas/Ft. Worth Chapter MTFCA
(Print out this form, fill it out and mail to the address at the bottom)

Name ____________________________________________         Birthday (mo/day)_______________

Street__________________________________ City________________ State_____  Zip___________

Home Phone ______  ___________________                      Work Phone _____ ___________________

Spouse Name ________________________________                    Birthday (mo/Day) ______________

Email Address_____________________________        Spouse Work Phone _____  ________________

Are you a member of MTFCA?    Yes ___   No ____      Member No. __________________________

Model T Information

Year Model Is it Running?
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Liability Release
The undersigned hereby agrees, as a condition of my participation in Chapter activities, of the Dallas/Ft. Worth Chapter of the Model T Ford Club of America, that said participation is for my own pleasure and that I will be fully responsible for my car(s) and passengers at all times. I hereby release from the Dallas/Ft. Worth Chapter and the Model T Ford Club of America, its assignees, officers, agents, officials and their successors from all liability whatsoever for any act, thing or event that might transpire during my membership. It is further agreed that vehicle(s) owned by the undersigned will at all times be operated by licensed drivers and said drivers will at all times comply with all applicable provisions of the licensing state. In addition, it is agreed that all said vehicles will be properly licensed, insured and equipped in accordance with the licensing state.

Member Signature_______________________________________        Date__________________

Spouse's Signature_______________________________________        Date__________________

 
Membership includes newsletter and one copy of membership directory....... $12.00
Make Check Payable to D/FW Chapter MTFCA  
Mail to: Lone Star T's, 627 Olympic, Richardson, TX 75081

Don't Forget to Join the National Organization - Model T Ford Club of America

 

Rev 2/24/03