Name ___________________________________________________________________

Address__________________________________________________________________

_________________________________________________________________________

Post code____________________________Tel__________________________________

Date_______________

Details of Lancia currently owned:

Model	Body	Series	Reg. No	Year

Is your Lancia your ever day transport? Yes No
How many miles do you cover per year? ___________

Type of Membership Required?
(please tick box) Single Family Overseas

Subscription payable £ _____ :00

Cheque/P.O. Number _________________

made payable to LANCIA MOTOR CLUB LTD'

PAYING BY CREDIT / SWITCH CARD?

Barclaycard/Visa Access/Mastercard Switch

Card No.

Switch issue No.__________ Issue Date/Valid From__________________________________

Expiry Date_______________________Cardholders Name____________________________

Cardholders address if different from above address_______________________________

____________________________________________________________________________

Signature_______________________________________ Code Web 2005

Please post to: Membership Secretary. Lancia Motor Club Ltd, 6 Halifax Road, Ainsdale, Southport PR8 3JU

Registered address:-Lancia Motor Club Ltd 16 Malvern Avenue Shepshed Loughbough Leics LE12 9ES

Registered in England No 1447373
.