Midwest Mopars Membership Application

If Midwest Mopars sounds right for you, print out this form, enclose a check and mail to:

Midwest Mopars Inc, - 22350 Monroe Street. N.E. - East Bethel, Mn 55011

763.559.1476

Name: ______________________________________________________________

Address: ____________________________________________________________

City:_________________________ State: _____________  Zip: ________________

Spouse: ______________________   Children: ______________________________

Home phone #: _____________________  Work phone #: _____________________

Occupation: ____________________________________________________________

 E-mail address: ________________ ________________________________________

Mopar owned - Year/make/model_________________________________________

Other Mopars owned:__________________________________________________

____________________________________________________________________

Have you been a member before?  Yes or No – please circle on – Thanks

If yes, do you know your membership number ___________

Club Directory – would you like your name listed? Yes or No – please circle – Thanks

Referred by: __________________________________________________________

 All information is considered confidential and is used for club purposes only.
No information will be released without the prior consent of the member.

 Office use – Check #________ Amount _________ Date_________