TRANS AM CLUB OF AMERICA, GOLDEN STATE CHAPTER

                                                                                    P.O. Box 465

                                                                          Fair Oaks, CA 95628-0465

                                                   APPLICATION FOR MEMBERSHIP

            NAME ______________________________________________________________________

            SPOUSE/SIGNIFICANT OTHER __________________________________________________

            CHILD _________________________________________________________ AGE _______

            CHILD _________________________________________________________ AGE _______

            ADDRESS____________________________________________________________________

            CITY_____________________________STATE _____________ZIP_____________________

            HOME PHONE________________________WORK  PHONE____________________________

            Year of Firebird____Color(int.)______(ext.)______Engine:__________ Auto______Manual_____

            Convertible_______T-Tops________Hardtop______

            Model(T/A,Formula,Firebird,GTA,etc.)______________________________________________

            Special Modifications____________________________________________________________

            ____________________________________________________________________________

            Email Address_____________________Personal Web Page Address______________________

            Special Interests: Rallies___Autocross___Drag Racing___Fun Runs___Show N Shine___

            Trips___Socials___Other__________________________________________

            Membership Type

            Newsletter Membership $20/yr._______ Full Membership - Individual $40/yr.______

                                                                                                                      Family $50/yr.______

            Please make check payable to , TACA, Golden State Chapter, and mail to