Bricklin International Membership Form

 Would you allow this information to be published on a roster available to other BI members?

Name: (First MI Last)			Spouse Name:
Street address:
Address (cont.):
City:			State/Province:
Country:			Zip Code:
Home Phone:			Work Phone:
FAX:
E-mail:
	I am a "Do-It-Yourselfer" (DIYer)

From the manufacturers plate at the bottom of the driver's door:

Complete VIN:

Date of Production:

-- mm/dd/yy

Date Purchased:	-- mm/dd/yy
Purchased From:
Current Color:
Current Finish:	-- (acrylic/paint)