Membership form
Kinsale Vintage & Classic Motor Club
Hon. Secretary: Ann O’Regan, Tuosist house, Knockleigh, Belgooly, Co. Cork
TEL. 00 353 (0)87 6822853 annsl350@gmail.com
www.kinsalevintageclub.com
MEMBERSHIP FORM
Application for New or Renewal of Membership. Please complete fully to upgrade club records.
BLOCK CAPITALS PLEASE.
Name: ______________________________ Address: ________________________________
Home Phone Number: ____________________ Mobile Number___________________________
Email Address: ___________________________ Occupation: ______________________________
Other Motor Club of which you are a member: ____________________________________________
Motor clubs of which you were previously member ________________________________________
Were you ever refused membership of a Club? ____________________________________________
Cars in possession: __________________________________________________________________
Make: __________________________________________________________________________
Model: ___________________________________________________________________________
Year of Manufacture: ________________________________________________________________
Condition: ________________________________________________________________________
Date of last Engineer’s report: _________________________________________________________
Are cars currently insured? ___________________________________________________________
If Yes, Name the Insurance Company: __________________________________________________
I declare that my vehicle will be fully insured (Under the Road Traffic Act 1961) For All Club Events.
I agree to abide by the rules and bye-laws of the Club.
Signed:___________________________________ Date: _________________________________
Proposed by: _________________(Club Member) Seconded by: _______________ (Club Captain)
SUBSCRIPTION: €35.00 single €50.00 Per couple or family. Per year. ৺� �A�P�
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