Application form

Please complete the following details, print the form out (ensure it all prints out) and sign it, and send a cheque/postal order for the amount indicated on the preious page. As we are currently rolling our membership up so all renewals will be done in April/May this amount will vary from month to month. As a rough guide please make your cheque/postal order out for £1 per month remaining until May 1st 2012. therefore applications submitted in October will be due to pay £7 and applications made in November will be £6.

Please send cheques and postal orders to the Membership Secretary, Adrian Southgate, 36 Eskdale Avenue, Blackrod, Bolton, Lancashire, BL6 5SE.

The membership subscription will be renewable on or before May 1st 2012, and covers 'The Member' and up to two additional 'Family Members' living at the same address (see notes on previous page). Please include the reg number and chassis number of your vehicle for our club register. Photo's also welcomed by email.

Please use capital letters throughout

MAIN MEMBER

Mr Mrs Miss Ms Other
Surname: First Name/s:

Family Members:

Mr Mrs Miss Ms Other
Surname: First Name/s:

Mr Mrs Miss Ms Other
Surname: First Name/s:

Address:
Town:
County:
Postcode:
Country: Other (please specify)

Telephone: E-MAIL:

Vehicle details: Please select the model, series number and body type (see Identify your Dutton if unsure)

MODEL

SERIES

BODY

REG NUM NOT REGISTERED:

CHASSIS NUM

ENGINE DETAIL

DRIVETRAIN

OTHER DETAILS



If you have any other Duttons that you would like to add, please write at the bottom of the page.


Confirmation:

I wish to join the Dutton Owners Club: ______________________________________________

Family members: _______________________________________________________________

All people wishing to join the club must sign above.

If you have previously been a member of the Dutton Owners Club, please indicate here:

Please print this form out, and send together with payment to the Membership Secretary (address at top of page). Your membership pack (including a windscreen sticker and copy of the latest club magazine) will be sent to you shortly, however, please bear in mind that the DOC is run by members in their spare time, so please be a little patient!