Pacific Northwest Region amt __________
Nash Car Club of America by ___________
Membership Application/Renewal exp __________
Name       Spouse     NCCA Membership #  
City       State or Province   ZIP or Postal Code    
Telephone         E-Mail      
Mail Completed Form to: Include your check made payable to: Pacific Northwest
Pacific Northwest Region, NCCA   Region, NCCA. Dues are $12 per year, and all dues
Jerry Knutsen, Treasurer   expire on March 1. Dues paid on or after September 1 are
150 Melrose Ave. E. #108   $6 for the remainder of the year until March 1. Dues paid
Seattle, WA  98102-5524   on or after January 1 include any remaining time until
(206) 328-4533   March 1 plus the entire following year.   Please remit in U.S. funds.  Thank you.
NOTE: Membership in the Nash Car Club of America is a pre-requisite for membership in the
Pacific Northwest Region.            
NCCA Recognized Cars Owned: (list additional cars on back if necessary)
Year Make Model # Model Name Body Style Condition *
*Note:  Use NCCA Condition Ratings  1 = Excellent   2 = Fine   3 = Very Good   4 = Good
5 = Restorable  6 = Parts Car