The Illini Collector Car Club

Membership Application and Renewal

Month and year you joined: ______________________  Birthdate: _____________________  (Year is optional)

Last Name: _______________________________  First Name: ____________________________  M.I. ______

Street Address:_____________________________________________________________________________

City: __________________________________  State: __________  Zip Code: _____________

Home Phone: ________________  Work Phone: ________________  E-mail: ____________________________

Employer and Occupation: __________________________/__________________________________________

(or Retired and Former Employer/Occupation: _________________________/___________________________)

Spouse's Name: ________________________________  Birthdate: _____________________  (Year is optional)

Spouse's Employer and Occupation or if Retired/Former Occupation: ___________________________________

Collector Car(s) Owned* (Add to back if necessary)
   *Rate Car Condition ( 1 - Original and running, 2 - Restored, and 3 - Not running)
Year: ____________  Make: ____________________  Model: _________________________  Condition: ______
Year: ____________  Make: ____________________  Model: _________________________  Condition: ______
Year: ____________  Make: ____________________  Model: _________________________  Condition: ______
Year: ____________  Make: ____________________  Model: _________________________  Condition: ______
Year: ____________  Make: ____________________  Model: _________________________  Condition: ______

Other Hobbies, Special Interests or Volunteer Work:

  Member: __________________________________________________________________________________

  Spouse:___________________________________________________________________________________

Club Activities That I Would Like To Participate In (Check All Those That Apply)

Club Officer: __________  Meeting Programs: ____________  Refreshments: _______________
Car Shows/Displays: _____________  Parades: ___________  Picnics: ____________  Banquets:  _________
Help Where Needed: _____________  Garage Tours: ____________  Road Tours and Rallys: ____________

Other Activities (List): _______________________________________________________________________

Event(s) I Can Organize: ______________________________________________________________________