Porsche Club of America, Arizona Region Membership Application Form

To become a member of PCA Arizona Region, complete the form below and mail with check in the amount of $42.00 payable to Porsche Club of America, and check in the amount of $18.00 payable to PCA Arizona Region to: Terry Martz, 4576 E. Chuckwalla Cyn, Phoenix, AZ  85044-6053, Phone (480)753-3241.

Name______________________________________________________________

Address____________________________________________________________

City_________________________State_______Zip Code (required)____________

Home Phone Number___________________Work Phone Number________________

Cell Phone Number___________________Email address______________________

County______________________________

*Family Member__________________________Relationship__________________

*Affiliate Member____________________________________________________

*Note: Member may name either Family or Affiliate, NOT both. They must be 18 or older.

PORSCHE INFORMATION:

Model_____________Body Type____________Year______Color___________________

Serial/VIN No. (Required)_____________________________________________

Car Used: Daily______For Pleasure_______

PCA REGIONAL ACTIVITY INFORMATION:

Age_______Occupation________________________

Single________Married_________Spouses Name_________________________

Name & Ages of Children_____________________________________________

My interests are: Technical____Drivers Ed____Autocrossing____Rallying____

Concours____Social____PCA Club Racing____

Porsche Maintenance is performed by: Self____Dealer____Independent____

Do you wish to be active in the events of the Club? Yes____No____

OK to list your address and phone number in our Regional Directory? Yes___No___

Signature: __________________________________________

I own (co-own) a Porsche, am 18 years of age or over, and agree to the Objectives of PCA, herewith apply for Active Membership in the Porsche Club of America.