Name of Club _________________________________________________
Name of Individual (associate membership) __________________________
Number of Club Members ________________________________________
Club Purpose _________________________________________________
_____________________________________________________________
Principal Vehicle Types in Club ____________________________________
National Club Affiliation (if any) ____________________________________

Name of Club President/Associate _________________________________
Address __________________________________________________
City and Zip _______________________________________________
Phone _________ Fax _________ E-mail ________________________
Club Web Site _____________________________________________
State if you wish the newsletter by mail or e-mail __________________

Name of Club Delegate to CCCCVA ____________________________
Address __________________________________________________
City and Zip _______________________________________________
Phone _________ Fax _________ E-mail ________________________
State if you wish the newsletter by mail or e-mail __________________

Name of Alternate  to CCCCVA ________________________________
Address __________________________________________________
City and Zip _______________________________________________
Phone _________ Fax _________ E-mail ________________________

Date of Application _____________________________________________
Signed by ________________________________ Club President/Associate

Clubs and individuals may join the council by submitting this application and a check for $10 to the CCCCVA. Print this application, make the check out to CCCCVA and mail to: