Competing __________ Associate ____________

Name: _______________________________Social Security#____________________

Address: _______________________________________________________________

(City)_______________________________ (State) _________ (Zip) _______________

Phone: (Home) _______________ (Work) ________________ (Cell) ______________

E-mail ___________________________ would you like newsletters e-mailed? Y or N
**Checks to be made out to, if not the same as above name and S.S. # or I.D. #

Name: ________________________________S.S. # or I.D. #_____________________
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Vehicle Name: ___________________________________________________________

NTPA Number: _______________________ Class _____________________________

Additional Vehicle Name: _________________________________________________

NTPA Number: _______________________ Class _____________________________
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Associate Dues: $30.00 _____________ (For non-competing members only)
Competing Dues:
Driver: $60.00 (After April 1st $85.00) _______________________

Additional Driver – Same Fee _______________________

Name: ____________________________________

Address: __________________________________

Phone: ____________________________________
Vehicle registration: $50.00 ______________________

Additional Vehicle: $50.00 ______________________

Total Dues Paid (To Date) ______________________

Contingency: $100 Paid with Dues (no contingency ad) _____________________
**To be in the point’s fund, you either need to pay $100
Or submit an ad for the Contingency booklet

Date paid____________ Check _______/Cash________ Amount _________________
Mail to: Karen Allen -Wolverine Pullers, Inc.
1482 S 1050 W
LaGrange, IN 46761