Application form
ABOUT YOURSELF
Family Name:  _____________________
Forename(s): ___________________
Address: ____________________________________________________________
 
              ______________________________________________________ _____
Telephone No:  _____________________
E-mail _________________________
JOINT MEMBERSHIP DETAILS (if applicable)
Forename(s): ___________________
Family Name:  _____________________
Address: ____________________________________________________________
 
              ______________________________________________________ _____
E-mail _________________________
Telephone No:  _____________________
ABOUT YOUR CAR (if applicable)
Model Name: ______________________
Model type (example L1): ____________
Date of manufacture: _______________
Steering type (RHD/LHD): ___________
Original (Yes/No):  __________________
Registration plate: _________________
Previous plate:  ____________________
Exterior colour:  ____________________
Original - Yes/No*
Interior colour: _____________________
Original - Yes/No*
Chassis no:  _____________________
Engine no:  ______________________
Engine type - tigre/standard*
First registered UK:  _______________
 
Previous owner:  _________________
_______________________________
_______________________________
*  Delete where applicable
History and present condition of vehicle . . .
Annual membership runs from 1 Oct   to   31  Sept  each year, and currently costs £18 or £21 for joint members at the same address.  Please print this form out, complete in block capitals and send together with your remittance to:
 
Denise Polley
Membership Secretary
Panhard et Levassor Club GB
"La Dyna", 11 Artierial Avenue, Rainham, Essex, RM13 9PD
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