Membership Form

You can print out this form and fax it, give us a ring so we can pick it up or email us the pertinent information

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Membership Form

Membership is $60 per year, per car, payable every January

Please make checks payable to Land Rover Club Panama

Date [mm/ dd/ yy] _____/_____/______

Name:                 __________________________________

Mailing Address:     _______________________________

                                  ________________________________

Home Phone:           _______________________________

Work Phone:              ______________________________

Fax:                             _______________________________

Cellular Phone:         ______________________________

Email Address *:        _____________________________

* best way to keep up to date with events!

Land Rover [Please specify if other brand]

Year _______________________________

Model _______________________________

Color _______________________________

Signature:________________________________________________

I wish to apply to the Land Rover Club Panama and I agree to abide

by the Constitution and By-Laws for the aforementioned Club.

[This code is valuable only if you observe it]

Contact information: TC 507-612-8684 Fax:507-236-8990

email [intraterra@yahoo.com or landroverclub@yahoo.com] Website: http://www.intraterra.com/