CCR MEMBERSHIP FORM 2010

                                                                                  Date __________________

                Name ____________________________Spouse ________________________

                Address :     Street ________________________________________________

                                     City ___________________ State ___________ Zip Code _____

                 Phone (home )_______________________ Phone (work) ________________

                 Fax _______________________________ Email ______________________

                 Make and Year of Automobile(s)                                                   Condition

                 (you do not need to own an antique or special interest vehicle to become a member)

                      _________________________________________________________________        ________________

                       _________________________________________________________________        _______________

                       _________________________________________________________________         _______________

                       _________________________________________________________________          ______________

                 You must be a member of the National ACA to belong to a Region.

                 Membership Number  ____________________

                  AACA application attached    Yes _____   No _____

                  Applicant’s signature ____________________________________________

                  Annual Dues:   $15.00                                       Please mail application to:

                  Please make check payable to:                          Mr. Steve Mackinnon

                  CCR – AACA                                                    55 Bow Drive

                                                                                              Avon, CT 06001

                                                                                              860-673-5817