Empire Z - Inland Z Car Club of Ontario, San Bernardino, Riverside, Redlands

On-Line Application
Empire Z Membership Application
(Information is submitted to one of the Club Officers)

First Name:               Last Name:
Date of Birth:    E-mail:
Home Phone: Cell Phone:
Current Address:
City:   State:   Zip Code:

Car Information

Year: Model: Color:

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

First Name: Last Name:
Date of Birth: E-mail:
Home Phone: Cell Phone:
Current Address: Relationship:
City:   State:   Zip Code:

Emergency Contact - Optional Information

Name of Relative not residing with you:
Home Phone: Cell Phone:
Current Address:
City: State: Zip Code:
Relationship:

Membership Fee & Privacy Policy

Membership Fee: Yearly membership is $35.00 per year - due March 1st. Dues are $17.50 after September through February.
Associate Membership Fee: Yearly associate membership is $10.00 per year - due March 1st. Dues are $5.00 after September through February.
Amount Submitted:
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 indicated a "Yes" answer to understanding this release and entering a date.

I understand and agree to the above release of liability Date:

You can pay your dues on-line if you have a PayPal account. Log-in to your PayPal account and make payment to: membership@empirez.com. Indicate in the Remarks section of PayPal that you are making a payment for dues. Be sure to complete and submit this Info Sheet/Application so we know who to apply the payment to.