Yankee Chapter
Membership
Application / Renewal Form
Date: _________ Renewal: _______ New
Applicant: ___________
Name(s):
_____________________________________________________
Address:
_____________________________________________________
_____________________________Zip:
____________________
Phone:
(
)_____________Email____________________________
Contact preference: Newsletter Phone Email
Year Buick Body
Style & Model Number Condition
_________ ________________________ ________
_________ ________________________ ________
_________ ________________________ ________
_________ ________________________ ________
Your BCA Membership Number:
_________________________________
Chapter dues are $20.00 per year and run from Jan thru Dec
Checks are made payable to: Yankee Chapter BCA
Please mail to: Glenn Tyler
54
Laurel Drive
Willington,
CT 06279-2247