Galaxies Northwest Membership Application

 

Name ____________________________       Date ____________

Address ______________________________________________

City ___________________ State (Province) _________________

Country _____________       Zip+4 _______________

E-mail __________________________

Phone ____________________

Your Car:  Ford or Mercury,  Year ____ Model __________________

Engine ______Transmission ______________ Color _____________

Optional: Include a photo

Do you own more than one Ford product? Please describe the rest (use the back if necessary):

 

 

 

 

Mail completed form plus $20 (annual dues) to: Galaxies Northwest
                                                                      3504 SE Claybourne St
                                                                      Portland, Oregon   97202-8247

Website: www.galaxiesnw.com