Golden Gate Austin Healey Club
     Membership Application
     and Renewal Form



Please include the following information:
      
      Date:__________________

      Name:________________________________________________
            
     Spouse: ______________________________________________

     Address: _____________________________________________

     City:  ____________________________ State:___ ZIP: ________

   
     Phone:  ____________ FAX: ___________ Cell : _____________

     Email address:  ________________________________________
    
    Healeys owned
                 Model:  _________   Serial number:___________________
                 Model:  _________   Serial number:___________________
                 Model:  _________   Serial number:___________________
                 Model:  _________   Serial number: __________________

Annual dues are to be paid by January 1, each year, for the coming year.     
     Annual Dues $25____
   

   

               Please make your check payable to
                The Golden Gate Austin Healey Club

                We'll see you on the road!
 
                Complete this form and send it, along with your check to:
               Nick Klein, 3334 Gardendale Drive, San Jose, CA 95118
              Checks should be made out to "Golden Gate Austin Healey Club"