Name(s): ______________________________________________________
Street Address: _________________________________________________
City: ___________________  State: _______ Postal Code: _____________
Country: _____________________ 

Telephone Number: ___________  Email Address: ________________________________

Would you like your telephone number printed in the MOCNA Roster?  Yes_____ No _____
Would you like your email address printed in the MOCNA Roster? Yes _______ No ______

Were you previously a member of MOCNA? Yes _____ No _____
If so, what was your MOCNA #? ______________________

Car #1
Year ______ Model __________  E# ______________  Chassis # _________
Color: ____________  Condition: ___________________________________
Car #2
Year ______ Model__________  E# ______________  Chassis # _________
Color: ____________  Condition: ___________________________________
<use back for more car information if necessary>

Referred to MOCNA by:  Mark & Rhonda Gelstein - Life Members 8616

Please send this form                DUES     USA and Canada Overseas
and dues to:                             1 year            $30              $39
                                               2 years          $54               $71
John Silman                                  3 years          $78               $108
MOCNA Membership/Treasurer      Life Member    $400             $500
P.O. Box 8661
Santa Rosa,  CA  95407-1661

OR - email this form to johnsil@sonic.net.  You can pay your MOCNA dues through PayPal using this same email address.  If emailing membership form, you are not enrolled as a member until dues have been received.