Name:____________________________________ Spouse/Mate:____________________________

Address:________________________________________________________________

City:_________________________________Prov/State:________________Postal Code/Zip:_______

Phone:________________________Country:_________________________Date:_________________

Email:________________________________________________

Pontiac's Owned:

Year:___________Model:_________________Style:_____________________

Year:___________Model:_________________Style:_____________________

Do you object to being listed in a Club Directory for members? Y / N

Other Car Club Affiliations:_____________________________________________________

How did you learn of Pacific Performance Pontiac Club?______________________________

____________________________________________________________________________

Please indicate any areas of interest or expertise you could make available to the club or members?____________________________________________________________________

____________________________________________________________________________

Signature:_________________________________

Dues are $30.00CDN per year pro-rated to Feb 1st. Please contact Membership Chairman for details.

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CLUB USE ONLY