Name of Club ____________________________________________
Name of Individual (associate membership) _____________________
Number of Club Members ___________________________________
Club Purpose ____________________________________________
___________________________________________________
Principal Vehicle Types in Club _______________________________
National Club Affiliation (if any) _______________________________

Name of Club President/Associate ____________________________
Address _____________________________________________
City and Zip __________________________________________
Phone _________ Fax _________ E-mail _____________________
Club Web Site ________________________________________

Name of Club Delegate to CCCCVA _______________________
Address _____________________________________________
City and Zip __________________________________________
Phone _________ Fax _________ E-mail _____________________

Name of Alternate  to CCCCVA ___________________________
Address _____________________________________________
City and Zip __________________________________________
Phone _________ Fax _________ E-mail _____________________

Date of Application ________________________________________
Signed by ___________________________ Club President/Associate

Clubs and individuals may join the council by submitting this application and a check for $10 to the CCCCVA. Print this application, make the check out to CCCCVA and mail to: