Low Country Mud Rats Membership Application

An asterisk (*) indicates a required field.

                     

Personal Information
* First Name:
* Last Name:
* Address:
* City:
* State:	-- select one -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other
* ZIP:
* Home Phone:
Business Phone:
* E-Mail:
Spouse's First Name:
Spouse's Last Name:
Additional Information
* Do you own a Jeep?	YES NO
* If So, Year:	Model:
* Pick your level of Off-Road Experience:	BEGINNER INTERMEDIATE ADVANCED
How did you hear about the club?:
Emergency Information
* Emergency Contact Name:
* Emergency Contact Phone:
* Insurance Company Name:
* Medical Prescriptions/Allergies:
In order to join the Low Country Mud Rats, you must meet the following requirements:
* Be the registered owner of any Jeep Vehicle * Maintain auto insurance on said vehicle, as required by Georgia State Law * Agree to keep vehicle in safe operating order, per federal, state, and/or local law * Possess a valid drivers license * Be at least 18 years of age
By initialing below, you agree to the Low Country Mud Rats by laws, trip/trail rules, and vehicle requirements. You further more agree to the annual membership dues of: $10.00 per year.
* Initials:

Content is the property of the Low Country Mud Rats. ©2007
Jeep® is a registered trademark of the DaimlerChrysler Corporation.
Questions or comments?