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MEMBERSHIP APPLICATION FORM:
DATE OF APPLICATION: ___/___/___
[ ] New [ ] Renewal
#________
Name:_(First)_________________(M)_____(Last)____________________________
Company Name:(Optional-Req. for businesses)_____________________________
Address:_______________________________________________________________
City, State, Zip:________________________________________________________
Home Phone:_______________________ Work Phone:_______________________
Fax:___________________________ E-Mail:_________________________________
Optional: (Required for family membership)
Spouse:___________________
Dependent Child(ren)___________________________________________________
Application Type:
__ Individual ($24 year) __ Family ($26 year)
__ Business ($36 year)
Description of multi-stop trucks owned (if any:) (Include year,
model, condition, etc.)
Membership Directory release: (Check one)
___ YES, please list me with this information in the next Membership
Directory.
___ NO, please DON'T
list this in the Membership Directory.
Sorry, applications must be mailed to be processed.
Just print this page and mail it along with a check for dues to:
Divco Club of America, PO Box 1142, Kingston, WA 98346-1142
Thank you for your interest!
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