MEMBERSHIP APPLICATION

Member's Name (LAST): |__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Member's Name (FIRST): |__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Spouse / S.O. Name (OPTIONAL): |__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Telephone Number: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Street Address: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|

City: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|

State: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|

ZipCode: |__|__|__|__|__| - |__|__|__|__|

Country: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Date of Birth: |__||__| - |__|__|  (MM - DD)

Email Address: (Please Print Clearly) _______________________________________________

Web Page: ____________________________________________________________________
Member Directory:

Only the information you indicate will be listed in the Member Directory
(accessible by members only).
Please indicate below what information you would like to have listed in the Member Directory.

|__| Name    |__| City / State / Country    |__|  E-mail address

|__|  Web Page    |__|  NO Information 

Your 300M Statistics: (If you wish, you may include a picture of your "M" for us to scan for the web site)
Model Year:

|__| 1999   |__| 2000   |__| 2001   |__| 2002   |__| 2003  |__| 2004        |__| Enthusiast Membership  (Love this car, but don't own one yet)
Exterior Color:
|__| Black Clear Coat |__| Deep Slate Pearl Coat
|__| Bright Platinum Metallic Clear Coat |__| Forest Green Pearl Coat
|__| Brilliant Black Crystal Pearl Coat |__| Graphite Metallic Clear Coat
|__| Candy Apple Red Metallic Clear Coat |__|
Inferno Red Tinted Pearl Coat
|__| Champagne Pearl Metallic Clear Coat |__| Light Almond Pearl Coat
|__| Cinnamon Glaze Metallic Clear Coat |__| Light Cypress Green Pearl Coat
|__| Dark Garnet Red Pearl Coat |__| Shale Green Metallic Clear Coat
|__| Deep Amethyst Pearl Coat |__| Steel Blue Pearl Coat
|__| Deep Cranberry Pearl Coat |__| Stone White
|__| Deep Lava Red Metallic Clear Coat |__| Future
|__| Deep Sapphire Blue Pearl Coat |__| Future
Factory Options :
|__| PHG (Performance Handling Group) |__| 360 Watt/11 speaker Stereo Upgrade
|__| 17" Chrome Wheels |__| Sunroof - Power
|__| 17" Silver Painted Wheels |__| Cold Weather Group
|__| 16" Chrome Wheels |__| Smokers Group
|__| 16" Silver Painted Wheels |__| Luxury Group
|__| Full Size Spare Matching Rim |__| Front Side Impact Airbags
Interior Color :
|__| Agate
|__| Camel/Tan
|__| Dark Slate Gray
|__| Light Pearl/Beige
|__| Light Taupe
|__| Sandstone


Mopar accessories added:__________________________________________________________________________________________

 _________________________________________________________________________________________________________________


After-Market Accessories / Modifications added:_________________________________________________________________________

  ________________________________________________________________________________________________________________
Desired Method of Dues Payment:  |__|  Personal Check / Money Order   |__|  Credit Card using PayPal
Membership Dues are $14.95 (U.S. funds) annually)

Please send this form along with a check to:
Chrysler 300M Enthusiasts Club
c/o Paulette Waters, Treasurer
1270 Del Lilly Ln
Las Vegas, Nevada 89123
or . . .

If you want to pay by Credit Card, check the PayPal box above and click on
the PayPal button below to complete the transaction.


Office Use ONLY: Membership # |__|__|__|__|__|__| Date Rec'd: |__|__|__|__|__|__|__|__|Check/M.0. # |__|__|__|__|__|__|__|__|__|__|__| 

 or PayPal TX # |__|__|__|__|__|__|__|__|__|__|__|
CHRYSLER®, 300M®, and the 300M®shield graphic are all registered trademarks of DaimlerChrysler Corporation.
This club and this web site are not affiliated in any way with DaimlerChrysler Corporation.
The Chrysler name and related trademarks are used with the permission of DaimlerChrysler Corporation.