DUES FOR WEST TEXAS REGION AACA: $5.00 PER PERSON OR FAMILY

 MAKE CHECK PAYABLE TO:   WEST TEXAS REGION A.A.C.A.
MAIL THIS FORM TO:  JOHN HOLMES
                                                3310 STANOLIND
                                                      MIDLAND, TX 79707

MEMBERSHIP IN THE NATIONAL A.A.C.A. IS A PREREQUISITE FOR MEMBERSHIP IN THE LOCAL

CLUB. IN ORDER FOR YOU FAMILY TO PARTICIPATE IN LOCAL EVENTS A FAMILY MEMBERSHIP

IN THE NATIONAL A.A.C.A. IS REQUIRED BY THE CLUB INSURANCE CARRIER.

NAME: _________________________________________________________

SPOUSE'S NAME: _________________________________________________

ADDRESS: ___________________________________________________________

CITY: __________________________ STATE: __________ ZIP CODE: ___________

I HAVE PAID MY 2006  NATIONAL A.A.C.A DUES:  YES ______   NO ______

(Mail your National dues directly to A.A.C.A. at Hershey, PA)

NATIONAL A.A.C.A. MEMBERSHIP NUMBER: __________________________

RESIDENCE PHONE: _________________ BUSINESS PHONE: ___________________

BIRTHDAY (Month and day only): HIS__________________ HERS__________________

ANNIVERSARY (Month and day only): _______________________

PLEASE HELP US KEEP OUR RECORDS UPDATED AND FILL OUT THE BELOW INFORMATION ON 
 YOUR ANTIQUE CAR OR CARS                

                                                                                                                                                                CONDITION:  0 - Original
                                                                                                                                                                                          R - Restored
                                                                                                                                                                                         IP - In Progress

            YEAR        MAKE                                                                       MODEL                                                                    CONDITION

1.                                                                                                                                                                                                                            

2.                                                                                                                                                                                                                            

3.                                                                                                                                                                                                                            

4.                                                                                                                                                                                                                            

5.