Midwest Pullers Association

2010 Membership Application

Please print clearly

Date:_____________ Payment: Check #____________ Cash:___________

Please check one: Competing Member ________ Associate Member ________

First Name ______________ Middle Initial _____ Last Name _______________

Address: ________________________________________________________

City/State/Zip: ____________________________________________________

Social Security Number (Required for Insurance): ________________________

Home Phone: ____________________ Work Phone: _____________________

Cell Phone: _____________________ Email Address: ____________________

Vehicle Information

Class: __________________________________________________________

Make/Model: _____________________________________________________

Vehicle Name: ____________________________________________________

Associate Member to:______________________________________________

Membership Fees:

Competing Member $100.00 (Paid on or before May 23rd, 2010)

$125.00 (Paid after May 24th, 2010)

Associate Member $25.00

Please make all checks payable to Midwest Pullers Association

If mailing in your application please return this form and payment to:

Midwest Pullers Association

P.O. Box 1727 www.midwestpullers.com

Ames, Iowa 50010

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Keep this bottom portion as a receipt.

Midwest Pullers Association 2010 Membership

P. O. Box 1727 _____Competing Member

Ames, Iowa 50010 _____Associate Member

Received From:_______________________ By:_________________________

Date:________ Amount:________ Payment: Check #__________ Cash:______

www.midwestpullers.com Thank You