BRICKLIN    INTERNATIONAL
Membership    Form
Personal Data

Name: _____________________________________	Spouse: ____________________________
Street: ___________________________________________________
City:   _________________________________	State:  __________  
Country:  ____________________	Zip   __________________
Phone Home:  (_____) ___________________	Phone Work:  (_____) ________________________
Phone FAX:  (_____) ___________________	E-mail Address:  _____________________________
I hereby give my consent to have my info. listed in the Bricklin Roster:  (          )
I am a Do It Yourselfer (DIYer)  (          )             B.I. Member since:_________________

Vehicle Information

Complete VIN #: __________________________________   Production Date (mm/dd/yy) _____________
            (From the manufacturer’s plate at the bottom of the driver's door)
Date Purchased:  ________________________	From Whom:    _____________________________
Auto: _______  4spd __________	Street address:  _____________________________
Current mileage: _________________________	City:                  ____________________________
Current Finish:(Paint or acrylic)  _________________________	State:  ____________
Current Color:  _________________________
If sold - To whom: _________________________________________________________

Any additional information, comments to improve the club, looking for parts, selling parts....
(Feel free to attach additional sheets of paper.)

__________________________________________________________________________________________
__________________________________________________________________________________________
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                        Dues:$50.00 U.S. and Canada in U.S. Dollars / International $60.00 in U.S. Dollars.

                        Dues:                                        _____________________
                        Additional Donation to club:   _____________________
                        Total:                                        ______________________	
Please make checks/money orders payable to: Bricklin International
Return Form & Remittance to:

	Jeff Sheehan, VP Membership B.I.
				   416 Main Street
				   Caledonia, MN 55921
				   507-990-9768