CAROLINA TRAILBLAZERS 4WD CLUB, INC.

MEMBERSHIP APPLICATION

For more information call the TRAILBLAZERS HOTLINE (828) 328-6264

Return completed application along with check (no cash) payable to:

Carolina Trailblazers / PO Box 291 / Conover NC 28613

Name ____________________________________________________ Birthday _______________________

Spouse's Name ____________________________________________ Birthday _______________________

Amateur Radio Call Sign ________________________ E-Mail _____________________________________

Address ________________________________________________________________________________

City __________________________________________________ State _________ Zip ________________

Home Phone (_______)________________________ Work Phone (_______)________________________

Cell Phone (_______)____________________________ Pager (_______)___________________________

Notify In Case of Emergency _______________________________ Phone (_______)__________________

YOUR 4WD VEHICLE(s)

Year __________ Make _____________________ Model _____________________ Color ______________

Lifted? _____ Winch? _____ Lockers? _____ On-board Air? _____ Tow Hooks? _____ Hi-Lift Jack? _____

Tow Strap? ____ Tree Strap? ____ Fire Extinguisher? ____ First Aid Kit? ____ Battery Hold Down? ____

Year __________ Make _____________________ Model _____________________ Color ______________

Lifted? _____ Winch? _____ Lockers? _____ On-board Air? _____ Tow Hooks? _____ Hi-Lift Jack? _____

Tow Strap? ____ Tree Strap? ____ Fire Extinguisher? ____ First Aid Kit? ____ Battery Hold Down? ____

ANNUAL CLUB DUES: $60.00 + $5.00 new member initiation/late-fee if/when applicable

DUES PAID $______________ + INITIATION/LATE-FEE $______________ = TOTAL $______________

SPONSORING MEMBER __________________________________________________________________

Some of our sponsors have requested a list of Trailblazer members. Those sponsors will sometimes offer discounts to members who are on that list. The list will be of names-only and will contain no other personal information. This is a personal choice each member must make. If the line directly below is not checked, your name will automatically be submitted to that list.

_____ I DO NOT want my name to be on any list being sent to sponsors.

The Carolina Trailblazers 4WD Club, Inc. assumes no liability for any personal

injuries or damage to vehicles or property during any club function.

SIGNATURE ________________________________________________ DATE _____________________

DEADLINE FOR PAYMENT OF ANNUAL DUES IS OCTOBER 15th

(include a $5 late-fee with all dues payments made after the deadline)