Please mail this form and regisration fee to: 77 Lake of the Pines East Stroudsburg, Pa. 18301

POCONO PERFORMANCE CAR CLUB MEMBERSHIP APPLICATION PLEASE PRINT

NAME _______________________________________________________________________ ADDRESS ___________________________________________________________________ CITY & STATE ________________________________________________________________ ZIP CODE ____________________________ HOME PHONE # _______________________ E-MAIL ____________________________________ SPOUSES NAME________________________________MEMBER ___YES____NO MAKE OF CAR ______________________________________ MODEL ____________________________________________ YEAR ______________________________________________ MAKE CHECK PAYABLE TO --- POCONO PERFORMANCE CAR CLUB INC. $10.00 PER MEMBER FOR INFORMATION PLEASE CALL STEVE GRAMPP 570-588-3071