MEMBERSHIP APPLICATION (NEW OR RENEWAL) For renewals, please check ( ) box if there are no changes to your current listing in the directory.

Name: ________________________________________________________________ Spouse: ________________________________________

Address:_______________________________________________________________ Phone No. (H): __________________________________

City: _________________________________ State:_________Zip: _______________ Phone No. (W): __________________________________

E-mail: ________________________________________________________________ FAX: __________________________________________

I am a member of National CCCA (Required) Yes ____________________________ or (Re) Joining ___________________________________

I carry liability insurance for any vehicle(s) I bring to CCCA events _______________________________________________________ (required).

Date: __________________________ Signature: ______________________________________________________________________________

ADDITIONS TO CURRENT LISTING: (List only those cars approved by the Classic Car Club of America)
Make of Classic, Year, No. of Cylinders., Model or Series, Body Style, and Body Maker (Only if Custom) Please list additional cars on the back.

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

DELETIONS TO CURRENT LISTING:
Make of Classic, Year, No. of Cylinders, Model or Series, Body Style, and Body Maker (Only if Custom)

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

Annual dues are $30.00 per year. To apply, print and fill out this form. Include a check payable to "CCCA NorCal" and mail to:

Ed Holloway, PO Box 123 , Walnut Creek CA 94597