| Iowa Street Rod & Custom Association |
Web Page
His Hers Last
Name: ____________________________________________________________________
(Please Print)
Mailing Address: ___________________________________________________________
City: ____________________________ State: _____________________ Zip: __________
Phone____-____-______ E-MAIL_______________________@____________________
Do you wish to have your e-mail published in the "Directory - Handbook"? Yes____ No ____
Do you wish to be listed on the ISRA emergency travel list in the "Directory-Handbook"?** Yes___ No ____
Mechanical _____ Transportation _____ Lodging _____ Social _____ All _____ Phone ______-______-______
Do you wish to have your vehicle picture on the ISRA web page? yes___ no___
Do you have your vehicle inspected buy the NSRA inspectors? yes___ no___
Vehicle #1: Year ______ Make ___________________ Model _______________________
Vehicle #2: Year ______ Make ___________________ Model _______________________
Local Club Affiliation: _______________________________________________________
(for Newsletter Only)
His Birth Date: ________ __________ Her Birth Date: ________ ___________
MONTH DAY MONTH DAY
Signature:__________________________________________
(Please Check Membership Type Below)
_____ $30 Singles & Couples ____ New Membership
____ Current Membership(renewal)
____ Previous Membership(renewal)
Make Checks Payable to ISRA and Send to:
ISRA - Membership **Members on this list maybe able to help in the areas that they
Harley Alcox checked: Mechanical, Transportation, Lodging, Social, All
66211 - 248th St.
Nevada, IA 50201
Referred By: ___________________________________
Name: ____________________________________________________________________
(Please Print)
Mailing Address: ___________________________________________________________
City: ____________________________ State: _____________________ Zip: __________
Phone____-____-______ E-MAIL_______________________@____________________
Do you wish to have your e-mail published in the "Directory - Handbook"? Yes____ No ____
Do you wish to be listed on the ISRA emergency travel list in the "Directory-Handbook"?** Yes___ No ____
Mechanical _____ Transportation _____ Lodging _____ Social _____ All _____ Phone ______-______-______
Do you wish to have your vehicle picture on the ISRA web page? yes___ no___
Do you have your vehicle inspected buy the NSRA inspectors? yes___ no___
Vehicle #1: Year ______ Make ___________________ Model _______________________
Vehicle #2: Year ______ Make ___________________ Model _______________________
Local Club Affiliation: _______________________________________________________
(for Newsletter Only)
His Birth Date: ________ __________ Her Birth Date: ________ ___________
MONTH DAY MONTH DAY
Signature:__________________________________________
(Please Check Membership Type Below)
_____ $30 Singles & Couples ____ New Membership
____ Current Membership(renewal)
____ Previous Membership(renewal)
Make Checks Payable to ISRA and Send to:
ISRA - Membership **Members on this list maybe able to help in the areas that they
Harley Alcox checked: Mechanical, Transportation, Lodging, Social, All
66211 - 248th St.
Nevada, IA 50201
Referred By: ___________________________________
| Membership Application |