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

The yearly due is $24, and payable
to: Southwest Missouri Miata Club, Inc
Mail to:
Bud Tarter
2182 S. Celebration,
Springfield,MO 65809