MEMBERSHIP FORM HEARTLAND T's of OKC Affiliated with The Model T Ford Club of America Print & complete this form and send it & $20.00 to: Mike Mayfield 1508 Vulcan Circle Edmond, Oklahoma 73003 Please print or type information Name___________________________________ Mailing address______________________ E-Mail__________________________ City____________________State_____Zip__________ Home Phone____________Work________________ Name of spouse____________________________ Are you a member of National_______________ National Membership Number__________________ Occupation______________Bus Name____________ Model T's Owned Year-----------Style------------Condition __________________________________________ __________________________________________ __________________________________________