Membership Application

Mid-West Gasser Association

MEMBERSHIP APPLICATION

Name__________________  AGE__________
STREET ADDRESS_____________________
CITY________________STATE____ZIP_____
EMAIL_________________PHONE#________

NOSTALGIA GASSER INFO

YEAR_____MAKE________MODEL________
ENGINE_______________________________
E.T. RANGE___________________________

YEARLY DUES:  
(Payable each October 1st.)
$50 For Racers
$40 For Non-Racers

Members Receive:
Club Decals
Membership Card

Print this Page and enter required information.

Send Completed Membership Application and check for $40 or
$50 along with PHOTOGRAPH OF CAR to:

MIDWEST GASSERS
14710 Wadsworth Road

Wadsworth, IL 60083