Michigan Buick Performance Club (aka Michigan Chapter - Buick Gran Sport Club of America) Membership Application 2011 - 2012

NAME:______________________________________________GSCA#:________________

ADDRESS:_________________________________________________________________

CITY:_________________________STATE:________________ZIP:___________________

PHONE:____________________________

email: _______________@_____________

BUICKS OWNED:____________________________________________________________

___________________________________________________________________________

BEST ET____________________BEST MPH________________________

INTERESTS:

Drag Racing________

Restoration_________

Shows _____________

COMMENTS:__________________________________________________________________

Do you need a nametag? _________Name to engrave _______________________________

DUES $15 US
 Send Check or Money Order to:

Michigan Buick Performance Club
Hemkers - Treasurer
15011 East Street Road
Montrose, MI 48457