Mid-Illini Jeepers, Inc. Club

Membership Enrollment Form

Name: _____________________________________________

Street Address: _____________________________________

City: ______________________________________________

State / Zip Code: ___________________________________

Home Telephone: ___________________________________

Work Phone (opt): __________________________________

E-Mail Address: _____________________________________

Jeep Information:
Model / Year / Color:

___________________________________________________

___________________________________________________

Membership Dues: $30.00/year.  Annual membership runs from January 2 thru December 31.  First time memberships will be accepted at any time during the year and will be pro-rated at $2.50 per month for the remaining months in the year.  Dues for the following year for all members are payable beginning December 1.  Dues must be paid by January 31 of the new year to remain a member in good standing.

Release of Liability: I hereby release the Mid-Illini Jeepers, Inc. Club (MIJC) and any other party or parties involved in any Mid-Illini Jeepers, Inc. Club activity of any liability whatsoever for any loss or damage to property or personal injuries sustained or occurring on any Mid-Illini Jeepers, Inc. Club event.  Furthermore, by signing this membership form, I certify that I am 18 years of age or older; and my vehicle used on any MIJC club events is street legal and properly insured according to the laws of the State of Illinois.

Applicant's Signature: ________________________________

Date Signed: ________________________________________

Please print off and mail to:

Fraser Yarker 4313 Meadow Drive Pekin, Illinois 61554

Make Checks Payable to: Mid-Illini Jeepers