Type in the information, then print out TWO COPIES on your printer
and send each to the appropriate address with proper funds. Ford Galaxie Club of America
Liberty Chapter Member Application

Date:   E-mail:
Name:
Address:
City: State(PROV):
Country: (Postal Zone) Zip+4:
Telephone: Can we put this in the club roster? Yes: No:
Are you willing to help a stranded member (within reason)? Yes: No:
Do you own a Galaxie? What year(s):
What model(s):
If you have more than one, let us know what engines, transmission, and body types so we can keep this on file for our parts data base for you to use.
I am interested in the following club services: Shows- Galaxie Gazette Magazine-
Parts Interchange Information-
Technical Service- Parts Location Service-
Being part of the technical information committee-Yes: No:
Free classified ads, 3 times a year-(this includes WWW exposure)
Member recommendation service-(any problems you have with a vendor or parts supplier, let us know and it is kept on record for other members. Sort of like BBB)
The member registry ( 70 page Buddy Book) is available for $11.00 to cover postage and printing US delivery.
Club cap with embroidered logo available for $12.00
pick cap color: dark red, cobalt blue, silver,
T-shirts: S, M, L, XL $18.00 XXL $20.00
Please send a photo of your Galaxie(s) so we can keep in on record and place it on the Internet.
(Subject to quality of picture approval.)
Life Memberships are available, however they do not include chapter dues.

Sorry, we CANNOT accept charge cards, except through PayPal
Mail one completed application with $40 and photo to: Any extra orders from above be sure to send to this address also.	Ford Galaxie Club of America P.O. Box 429, Valley Springs, Arkansas 72682-0429
and the second completed application with $10 chapter dues to:	Liberty Chapter - Ford Galaxie Club of America PO Box 1105, Media, Pennsylvania, 19063-1105 Make Check payable to: Kenneth Yeager