Empire Z Membership Application

Fill-in the Blanks  Applicant Information  Click on Print Form Button Below

First Name:   Last Name: Initial:

Date of Birth:  E-mail:

Phone (Home):   Phone (Cell):

Current Address:

City:   State:   Zip Code:

Car Information - Select from below

Year:   1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2023 2024    Make:   Datsun Nissan   Model:  240Z 260Z 280Z 280ZX 300ZX (Z31) 300ZX Turbo (Z31) 300ZX NA (Z32) 300ZX 2+2 (Z32) 300ZX NA > TT (Z32) 300ZX TT (Z32) 350Z (Z33) 370Z (Z34) Nissan Z (still Z34) Roadster GTR (R35)   Other:

Associate Membership - (Wife - Son/Daughter - Significant Other)

Name:   Relationship: Wife Son Daughter Grandson Granddaughter Brother Sister Niece Nephew Other

Date of Birth:  E-mail:

Phone (Home):   Phone (Cell):

Current Address:

City:   State:   Zip Code:

Emergency Contact - Optional Information

Name: 

Current Address:

City:   State:   Zip Code:

Relationship to Applicant: Wife Son Daughter Grandson Granddaughter Brother Sister Niece Nephew Other

Membership Fee & Privacy Policy

Membership Fee:  Yearly membership is $20.00 per year - due March 1st.  Dues are $10.00 after September 1st.
Associate Membership Fee:  Yearly associate membership is $10.00 per year - due March 1st.  Dues are $5.00 after September 1st.
Amount Submitted:   Select Amount $20.00 - Full Year Membership $30.00 - Full Year Membership/with Associate $40.00 - Full Year Membership/with two (2) Associates $10.00 - Partial Year Membership $15.00 - Partial Year Membership/with Associate $20.00 - Partial Year Membership/with two (2) Associates $10.00 - Full Year Associate Membership $5.00 - Partial Year Associate Membership
Privacy Policy:  All information submitted on this form will be held confidential by the officers of Empire Z.  Your personal information will not be sold or revealed to anyone without your specific permission.
I hereby state the above information to be true.

Release of Liability

I hereby release Empire Z, its officers and members, from any liability due to accident, injury, theft, or any other reason while attending or participating in any and all Empire Z events and/or functions.  Membership Application is not complete until you have signed the release of liability.

Signature of Applicant: ______________________________________  Date:

Signature of Associate Applicant: _____________________________  Date: