Membership Application

Name___________________________________ Birthdate____________________

Spouse__________________________________Birthdate____________________

Address_________________________________  Phone______________________

City______________________________ State__________ Zip Code____________

Email address:_____________________________@__________________________

Insurance Co.____________________________ Policy No._____________________

List Year and Model of Ford Truck(s) owned. List all modifications and special features:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

I understand that the First Coast F-100 & F-1 Club of Jacksonville, Fl  will not be held responsible for the actions taken by any individual member(s). I will not hold the First Coast F-100 & F-1 Club of Jacksonville, Fl. responsible for any actions taken for the benefit of the club. I understand I will maintain state required insurance on all vehicle(s) involved in any club functions. Therefore: I will not hold the First Coast F-100 & F-1 of Jacksonville, Fl. liable.

Applicant's Signature:________________________________ Date:______________

Sponsor's Signature:_________________________________ Date:______________

President's Signature:_________________________________Date:______________

Acceptance of this application will be by an approving vote of the club membership during the next
regular meeting. Dues is $25.00 per year

Print out and Complete
Hand in at our regular meeting  or  FAX : 904-391-0043