Name: ___________________________________________________________________
Passenger's Name:__________________________________________________________
Address: ___________________________________________________________________
City: ___________________________________________ State ________ Zip _______
Phone # - Home: ___________________ Work: _________________________________
Email Address: _______________________________________________________
How did you hear about the club? __________________________________________
Miata Year _____ Model ________ Color ________ Vanity Plate# _______ (opt.)
Your miata has:
_____ Air Conditioning
_____ Cd Player
_____ Package
_____ Abs Brakes
_____ Automatic
_____ Limited Slip Dif
_____ Hard Top
Aftermarket Options Installed: ____________________________________________
What activities would you like the Miata Club to do? ______________________
Have you, or do you belong to another car club? ___________________________
Current Dues: $30 per household. This entitles you to full
club membership, and the newsletter for one year. Send check (made out to MidState Miata
Club) and a completed printout of this form to: Lee Maddy, Treasurer - MidState Miata
Club, 40 Parkington Circle, East Syracuse, NY 13057. Any questions, contact Bob Sabella -
Membership Chairman (315) 463-9643, or E-mail him at: 
