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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