ICOA Membership Form

Please check as appropriate:
____ New Member ____ Renewal ____ Address Change
ICOA Member Number ________
Referred to the ICOA by ___________________________________

Membership Dues

____ $30 USA
____ $34 Canada
____ $38 Overseas
OPTIONAL: Direct Support of Team T and The Bonneville CBX Race Team $__________

Please send funds in U.S. dollars drawn on a U.S. bank, checks made payable to I.C.O.A.
Card Number: _____________________________ Expiration Date: ________
Signature: ________________________________________________

Please print
Name: ________________________________________________
Phone: ________________________________________________
Address: ______________________________________________
City: _________________________________________________
State/Province: _________________________________________
Country: ______________________________________________
Zip or Postal Code: _____________________________________
E-Mail: _______________________________________________

Do you want to be listed in the Membership Directory? ____ Yes ____ No

Description of Your CBX(s): (optional)
Frame Number (VIN): __________________________________
Engine Number: _______________________________________

I understand the the International CBX Owners Association can not assume responsibility for any aspect of my safety and that, if I participate in any Association event, I do so voluntarily on my own assessment of my ability, the routes, and all facilities and conditions, assuming all risks; and I release and hold the International CBX Owners Association, its members and officers, harmless for any injury or loss to my person or property which may result therefrom. I also hereby certify that I am in compliance with my state's financial responsibility laws regarding the carrying of proper insurance.

Signature required: ____________________________________________________ Date: ________________

Send form and dues to:

ICOA Membership
c/o Bill Hertling
Box 2826
Bluffton, SC 29909  USA