INFORMATION AND CONDITIONS OF MEMBERSHIP: National Membership is a prerequisite to Regional Membership. As a condition of membership, all members must abide by all rules published by the National and Regional boards. Regional membership must be confirmed by the Board of Managers. The annual dues of $25.00 cover the remainderof 2010(thru December 31, 2010). Make checks payable to: WISCONSIN REGION CCCA, INC.Fill out the form below and remit the membership fee of $25.00 to: 

                   Ron De Woskin
                   2980 Woods Edge Way
                   Fitchburgh, WI. 53711

                   Or contact him for more information at 608-274-8765 or rondewoskin@charter.net
Name:______________________________________________________________________________

Address:____________________________________________________________________________

City:_______________________________________________ State/Zip:_________________________

E-mail:________________________________________ FAX:____________________________

Phones:   (Home)_________________________   (Business)_________________________

Wife’s or life partner’s name (Or, that of National Associate Member)

___________________________________________________________________________________

ALTERNATE ADDRESS INFORMATION:

Name:______________________________________________________________________________

Address:____________________________________________________________________________

City:________________________________________________State/Zip:_________________________

Phone:____________________________

Dates to be used for mailing to the above address - From: __________________ To: __________________

LIST OF CLASSIC CARS OWNED. IF NONE, SO STATE:


MAKE YEAR CYL MODEL BODY STYLE BUILDER OF BODY
_______________ _____ _____ _______________ _______________ __________________
_______________ _____ _____ _______________ _______________ __________________
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List any additional cars on a separate sheet.