Peconic Bay Region AACA

2011 PECONIC BAY REGION AACA DUES AND MEMBERSHIP APPLICATION

PLEASE NOTE: IN ORDER TO BE A MEMBER OF THE PECONIC BAY REGION WHICH IS A LOCAL CHAPTER.

YOU MUST FIRST BE A MEMBER OF THE NATIONAL AACA

THERE IS A LINK TO THE AACA ON THIS WEBSITE

E-Mail Address:_______________________@___________________________

Last Name:____________________________ Spouse:_______________________

First Name:___________________________ Telephone #:__________________

Address:_________________________ Town:________________________State:_____ Zip:_______

AACA Membership # (Mandatory)____________

Membership $20.00 Annually

PBR MEMBERSHIP INFORMATION

Please complete this form and send a check made out to“Peconic Bay Region” for the correct amount in order to maintain your club membership through 2011. We must have your renewal by January 2011 in order to keep you name on our newsletter mailing list. Thank You.

If you are a single member of AACA you may only be a single member of the Peconic Bay Region. Joint members of the AACA may become Joint members of the Peconic Bay Region.

YOU MUST BELONG TO THE NATIONAL AACA TO BECOME A MEMBER OF THE PBR CLUB. PLEASE NOTE IF YOUR PBR MEMBERSHIP FORM WILL BE RETURNED TO YOU IF YOU ARE NOT AN NATIONAL AACA MEMBER.

Please list current antique vehicles which you own. Ownership of an antique vehicle is not required to join the PBR Club.

Year:_____________Make:________________Model:______________Body Style:_______________

Year:_____________Make:________________Model:______________Body Style:_________ ______

Year:_____________Make:________________Model:______________Body Style:_______________

Year:_____________Make:________________Model:______________Body Style:_______________

Please send payment and this form to: George Bartunek

21 Silver Beech Lane

Calverton, NY 11933