Membership Information Form

Welcome to the Central NY Chapter of the Chrysler Owners Group

The club that supports You !

First Name: __________________________________________________

Last Name:___________________________________________________

Birthday: ____________Month______________Day

Associate Member; (i.e. Spouse) _________________________________

Birthday: ____________Month______________Day

Address: _____________________________________________________

City:_______________________ State: __________________      Zip: ______

Home Phone: ______________________  Cell  Phone:_____________________

Email:__________________________________

Year of car: ________      Make: ___________________________ 

 Model: _______________________ Color:__________________________

No Dues, No Fees                             315-458-1796 for more information

Mail to:

Cathy DeWolf

Central NY Director

PT Cruiser Owners Club

26 Lee Terrace

N. Syracuse, NY 13212

Or copy the form, paste it to new mail and send it to CNYPT@verizon.net