Please check one of the following Memberships, and complete the information below:
____	912 Registry One-Year Membership, address within the United States - $25 U.S.
____	912 Registry One-Year Membership, address outside the United States - $40 U.S.
	Serial # / VIN:
	Year  ___ 1965 ___66 ___67 ___68 ___69 ___76
	Original Color (eg 6608):
	Odometer in Thousands:                                        ML    KM
	Body Style: ___Coupe ___Targa SW ___Targa HW
	* NonOwner (Associate) Member ____
	First Name:
	Last Name:
	Mailing Address:
	City:
	State/Province:
	Zip/Postal Code:
	Country:
	Phone:
	Email:
	PCA Region:
	PCA Member #:
	Comments?  Use back if needed
	Send this form and Check or Money Order to:
	912 Registry, Inc., P.O. Box 862219, Los Angeles, CA 90086