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
P.O. Box 598 Piedmont,
OK 73078
If you are not a member of The Model T Ford Club of America please add $ 40.00 for National dues. Please print or type information
Name___________________________________
Mailing address______________________
E-Mail__________________________
City____________________State_____Zip__________
Home Phone____________Work________________
Name of spouse____________________________
National
Membership Number__________________
Occupation______________Bus Name____________
Model T's Owned
Year-----------Style------------Condition
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