Date: _____________ E-mail: _________________________________

Name: _____________________________________

Address: ________________________________________

City: _______________________ State: __________ Zip: _______________

Telephone: ___________________ Can we put this in the club roster? Yes: _____ No: _____

Are you willing to help a stranded member (within reason)? Yes: _____ No: _____

Are you a: New Member: _____ Renewing Current Membership: _____ Amount paid: __________

Do you own a Galaxie? Yes: ___ No: ___ Year(s)/model(s): _______________________________________________

(You must be a member of the National Club in order to be a chapter member)

National Membership number_____________ Membership expires on:__________

For information on the Ford Galaxie Club of America please contact:       

PO BOX 429

Valley Springs, Arkansas 72682-0429

Phone: (870) 429-8264        

Please send this completed application with dues to Carolina Galaxies:        

1164 Furman Dr.

Sumter SC, 29154

phone: (803) 494-2219   

Chapter dues are:1 year = $10.00, 3 years = $25.00, 5 years = $40.00