Lancia Motor Club Membership Application Form

 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

*Family Membership includes wife, civil partner and/or children up to 17.

Subscription payable £ _____ :00

Cheque/P.O. Number _________________

made payable to 'LANCIA MOTOR CLUB LTD'

PAYING BY CREDIT / DEBIT CARD?

Barclaycard/Visa Access/Mastercard Maestro/Debit Card

Card No.

                                       

Maestro Issue No.__________ Issue Date/Valid From__________________________________

Expiry Date_______________________Cardholders Name____________________________

Cardholders address if different from above address_______________________________

____________________________________________________________________________

Signature_______________________________________ Code Web 2008

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, Loughborough. Leics LE12 9ES

Registered in England No: 1447373
.