DATE:___________/__________/___________

NAME:

Last____________________, First_____________________, Middle______________________


MAILING ADDRESS:

Box or Street ____________________________________________________________________

City______________________________, State/Province/County ________________________  

Zip/Postal Code _____________________

Country _____________________________


E-MAIL ADDRESS:_________________ @ _________________ . ________


TELEPHONE:

Home __________________________________, Work ________________________________

Fax ___________________________________

PAYMENT: (If paying by check, please make check payable to Society of Automotive Historians.)

Check Enclosed ____________, OR  (Circle One):    American Express     MasterCard    Visa 

Card Number______________________________, Expiration Date___________/__________/___________

Signed___________________________________, Credit Card Security Code (on card)______________

Please share your automotive interests: ______________________________________________

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