MEMBERSHIP FORM HEARTLAND T's of OKC

Affiliated with The Model T Ford Club of America


Print & complete this form and send it & $20.00 to:

Mike Mayfield
1508 Vulcan Circle
Edmond, Oklahoma 73003

Please print or type information

Name___________________________________

Mailing address______________________

E-Mail__________________________

City____________________State_____Zip__________

Home Phone____________Work________________

Name of spouse____________________________

Are you a member of National_______________

National Membership Number__________________

Occupation______________Bus Name____________

Model T's Owned

Year-----------Style------------Condition

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