Name:      Spouse/Significant Other: 

First Person's Birth Date (mo./day):         Second Person's Birth Date (mo./day):    

Florida Address:   City:   State:  ZIP: 

Northern Address (if applicable): 

Telephone Number:                    FAX Number: 

E-mail Address:           Other Phone: 

Miata Year:      Color:         Package: 

First Name(s) You Want On Club Badge(s):           

Please check the box next to the areas of interest you are willing to help the club, in the coming year:

Newsletter,Stories:                                                    NewsletterMailing, Advertising, etc.: 

Event Planning and Implementation:                          Club Officer or Area Events Director: 

Other Ideas (explain): 

IMPORTANT:  PLEASE READ CAREFULLY AND SIGN.  WITH YOUR SIGNATURE, YOU AGREE AND ACCEPT THE FOLLOWING STATEMENTS AND CONDITIONS: As a Member of the Miata Club of South West Florida, I agree to obey all traffic laws, including speed limits, and set a positive example for other drivers.  I acknowledge that any driving event, whether on a public road or on a track, involves danger and risk.  I will not hold the Miata Club of Southwest Florida, its Officers, Members or assigns responsible for any accident, mishap or injury that may occur during any activity or event, or during travel preceding or following such activity or event.

SIGNED:         DATE: 

SIGNED:         DATE: 

Membership fees for the Miata Club of Southwest Florida are $24 per year.  All memberships renew on April 1 of each year.  New Members who join for the first time after Oct 1 of each year will Pay $15.   Please send this completed Form, along with your check payable to: The Miata Club of Southwest Florida, to Donna Noyes, 17721 Canal Cove Ct. Fort Myers Beach FL33931.