First Coast Miata Club Membership Signup

We're glad to hear that you decided to join us for some 'Topless' fun in the sun. Please complete the following information and remember to check the club event's calendar so you can join us at the First Coast Miata Club Event!
*Denotes Required Field

Your Name:

Spouse's Name:

Street Address:

City:

State:

Zipcode:

Home Phone:

* Phone No. Format: 555-555-1212

Work Phone:

Cell Phone:

CB Handle:

E-Mail Address:

Please Describe Yourself:
The following information will be kept confidential except as approved, in advance by the member. Information collected on this form is used by the FCMC board to help provide us a better demographic understanding of our member base.

Marital Status:

Occupation:

Hobbies/Interests:

Date of Birth:

Date Format: MM/DD/YYYY

Sex:

Male

Female

How did you hear about us?

FCMC Contact Card:

Personal Contact:

Web Site:

Dealership:

Other:

General Neighborhood / Area of Residence?

May the following information be included in the Club Member Directory?

Name(s):

Yes No

Address:

Yes No

Phone Number:

Yes No

E-Mail Address:

Yes No

Car Information:

Yes No

CB Handle:

Yes No

About Your "Baby"

Miata Model Year:

Is it a JDM Miata?

Yes No JDM is Right Side Drive Imported from the Japanese Market

Package:

Color (Body/Top)

Performance Mods:

How will you be paying your dues today?

PayPal Check or Money Order* I will Pay in Person at the Next Meetng**

*The mailing address for club dues will appear after sucessfully submitting this form.

** Meeting times and locations are posted on the main site under 'Events'