Wichita 4x4 Club 2805 W. 59th N. Cir. Wichita  KS  67024

Membership Application Year ________ Renewal? Y/N

		__ $30 Regular	__ $40 Commercial

	        __ $10 One Time Fee __ $5 Associate
         

Name:_______________________________________________________________Birthday:__________ 

	LAST				FIRST		MIDDLE	             MM/DD 

Address:______________________________________________________________________

                  STREET					APT

_______________________________________________________________________________

                  CITY			STATE	              ZIP 

Other:______________________________________________________________Birthday: _______

	    LAST			FIRST     	MIDDLE	 		 MM/DD 

Anniversary: _______________

	             MM/DD

Telephone number(s): __________________________________________________

	Can the Club publish your information for use by club members only:  Y / N

Children:

VEHICLES:

Vehicle:________________________________________________________
        	MAKE	 MODEL	           YEAR           COLOR

Vehicle: _______________________________________________________
	        MAKE	 MODEL 		  YEAR		 COLOR 

Vehicle: _______________________________________________________ 
                MAKE	  MODEL           YEAR            COLOR

I/We hereby agree to abide by all By-Laws of the Wichita 4X4 Club.

I/We agree to conduct myself/ourselves in a manner that projects the best image and 
interest of this club while in attendance at meetings or other club activities.

Signed ________________________________________________Date ___________

Signed ________________________________________________Date ___________

Received by __________________________________________Paid ______Ck# ______

Invited or Sponsored by ______________________________Date _________