High Plains Auto Club
Membership Application

_______ __________________________________________________________

Membership Information	
Last Name:		
First Name:		
Spouse/Significant Other:		
Address:		
City:		
State:		
Zip Code:		
Phone:		
Email Address:		

Description of Vehicle	
Make:		
Model:		
Modifications:

Please list additional vehicles on the back of this sheet.	

Optional	
Birthdays:		
Anniversary Date:		

Membership Dues                         Cash                  Check	
Single        $24.00                            	
Couple      $30.00	

Signature:                                                                                Date:	

“Cruisin’ the Heartland”

High Plains Auto Club
P.O Box 254	
Scottsbluff, NE 69363-0254
Contact Person:
President Daryl Wills – (970)-219-4087