APPLICATION FOR MEMBERSHIP

For our Dixie Chapter to remain sanctioned, ALL chapter members must also be members of the national organization (POCI). We can handle both for you from this one application and one payment. Please make checks payable to:
Dixie Chapter, POCI
ANNUAL DUES:
National - $31.00
Dixie Chapter - $20.00

Print and return to:
Eric Decker
3339 Net Court
Jacksonville, FL
32277

_______ Year	_____________________________________ Model/ Style Number or VIN	______ No. Cylinders
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Owner:___________________________________________________________
Address:__________________________________________________________

City:__________________________________

State:________

ZIP:___________

Phone:(_______)_____________-_______________________________________

Associate Members:_____________________________________________________

E-mail Address:________________________________________________________

POCI # (if current POCI member):__________________________________________

Signature (must include):_________________________________________________