Heartland Chevelle Club

Membership Application

Name: ___________________________________________________________

Street Address: ___________________________________________________

City: ____________________________ State: ________ Zip: ____________

Phone: __________________________________________________________

Email: ___________________________________________________________

Chevelles Currently Owned: ____________________________________________

Other Club Affliations: ______________________________________________

Spouses Name: ___________________________________________________

 

Dues shall be Thirty Dollars ($30.00 U.S.) per year. The first year's dues will be prorated at the rate of $2.50 per month for the number of calendar months remaining from the date the membership begins to the end of that year.

PLEASE MAKE CHECKS PAYABLE TO: Heartland Chevelle Club

The club's website is http://heartlandchevelles.net

Please send the application to:

Connie Johnson (Treasurer)
9762 County Road 23
Blair, Ne 68008

Additional Contact Information for Connie: Phone: 402-690-2609 or Email: rdetjens@abbnebraska.com

 


Please feel free to print this web page, or alternately, this link will provide a WORD document for your use. ( HCC application )