*** SUBSCRIPTION FORM ***
- Club subscription request -
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Personal Information
Last name :
Surname :
Gender :
F
M
Address :
City :
Province :
Country :
Postal code :
Birth date (DD/MM/YY):
Res. Phone :
Off. Phone :
Oth. Phone :
Email :
Occupation :
Business :
Spouse name :
Children :
Preferred language :
Français
English
Car information
Brand :
Model :
Year :
Mileage:
Ext. Color :
Int. Color :
General information (Optionnal)
By who were your referred ?
MAGAZINE
Montreal Auto Show
Quebec Auto Show
Other member : Who ?
Média
Dealer : Which one ?
Do you own any other vehicles ? ?
If so, please specify :
Are you owner or tenant of your residence ?
Owner
Tenant
Annual family income before taxes ?
-$50 000
$50 000 / $100 000
$100 000 / $150 000
+$150 000
Which type of credit card do you hold ?
Visa
Master Card
American Express
Other :
To which activities will you assist ?
Rallyes
Autocross
Excursions
Driving courses
Monthly dinners
Elegance reception
Banquet
Grand Prix
Golf tournaments
Poker Run
Maple Lodge
Guinness Recorde
Adhesion to the Club
Adhesion to the Club :
1 an - $125
2 ans - $225
3 ans - $325
Additionnal member cards for family members :
$25 ch. X
Names on additionnal cards:
(seperated with a comma)
:
Sub-total :
$
GST (6%) :
$
Sub-total :
$
QPT (7.5%) :
$
GRAND TOTAL :
$
Output my credit card of the sum indicated.
I will send a cheque or Money Order by mail with the indicated amount.*
* My adhesion will be confirmed only when complete payment is received.
Credit card holder :
Card type :
Visa
Mastercard
Card number :
Expiry date :
/
By checking here, I agree to auto-renew my adhesion each year using my credit card.
I can cancel this agreement anytime by communicating with the Club adhesions service.
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