MINNESOTA IMPALA CLUB MEMBERSHIP APPLICATION
A Chapter of The National Impala Association
Name: ________________________________________________________________________
Last
First
Spouse
Address: ______________________________________________________________________
City: _____________________________________
State: _______ Zip: ________________
Date: ______________________
Home Phone:(___)____________________
NIA#: ______________________
Work Phone:(___)____________________
E-Mail: _______________________________________________________________________
Year and brief description of 1958-1970 full-sized Chevy(s) owned:
_____________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Question, Comments, or Suggestions:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Enclosed: _________ $20 per year
($10.00 for the remainder of the first year, August 1 though December 31)
Make check or money order (do not send cash) payable to:
MINNESOTA IMPALA CLUB
C/O GLORIA HARTMAN
20857 ITALY AVE
LAKEVILLE, MN 55044
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