PAA APPLICATION FORM

Name _______________________   Spouse Name      ___________________
Street ________________________________________________________
City ____________________ State _______________ Zip _____________
Telephone (______)___________________ Date _____________________
Email Address  _____________________________________________
Costs
Annual Dues $20.00
Please Complete Form and Send to:
Pioneer Auto Association
PO Box 1971
South Bend, In. 46634
Signature of Applicant _____________________________________
Recommended By ___________________________________________
List Antique or Classic Autos Owned: (list additional cars on back)
            Make                Model              Year              Condition
1. ______________ ___________ _________ ________________
2. ______________ ___________ _________ ________________
3. ______________ ___________ _________ ________________
4. ______________ ___________ _________ ________________
5. _____________ ___________ _________ ________________