Southwest Missouri Miata Club, Inc Membership Form

Membership Date:	___________________
Name:	_______________________________________
Spouses / Partners Name:	_______________________________________
Address:	_______________________________________
	_______________________________________
Home Phone:	_______________________________________
Cell:	_______________________________________
Email Address:	_______________________________________
Alternate Email:	_______________________________________
Date of Birth:	_______________________________________
Gender:	__________Male __________Female
Car Year and Color:	_______________________________________
Car Name:	_______________________________________
How long have you owned your Miata:	_______________________________________
Emergency contact. Normally someone NOT going on events with you.
Name:	_______________________________________
Phone:	_______________________________________
Your Interests:	_______________________________________
	_______________________________________
	_______________________________________
Do you wish to share your membership data with other members?
_____Yes	_____No

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The yearly due is $24, and payable to: Southwest Missouri Miata Club, Inc

Mail to:

Cheryl Fidell 4033 W. Tarkio St. Springfield, MO 65802