Application Form

Please complete the following details in block capitals, print the form out (ensure it all prints out) and sign it, and send a cheque/postal order to.

The Membership Secretary, Adrian Southgate, 36 Eskdale Avenue, Blackrod, Bolton, Lancashire, BL6 5SE.

The membership subscription covers 'The Member' and up to two additional 'Family Members' living at the same address (see notes on previous page). Please include the reg number and chassis number of your vehicle for our club register. Photo's also welcomed by email.

TITLE Mr Mrs Miss Ms Dr Rev

SURNAME

OTHER NAME

ADDRESS 1

ADDRESS 2

ADDRESS 3

ADDRESS 4

POSTCODE

COUNTRY

MEMBERSHIP NUMBER RENEWAL?

FIRST FAMILY MEMBER

TITLE Mr Mrs Miss Ms Dr Rev SURNAME

FIRST NAME OTHER NAME

SECOND FAMILY MEMBER

TITLE Mr Mrs Miss Ms Dr Rev SURNAME

FIRST NAME OTHER NAME

VEHICLE INFORMATION - please include chassis numbers where possible.

MODEL SELECT MODEL P1 B TYPE B+ B+ MALAGA MALAGA MALAGA B+ CANTERA MELOS SIERRA DH SIERRA PU SIERRA EST RICO RICO SHUTTLE BENETO LEGERRA PHAETON S1 PHAETON S2 PHAETON S3 PHAETON S4 SURF COMMANDER LAKELANDER OTHER REG NUM CHASSIS NUMBER ENGINE SELECT ENGINE 1100 XFLOW 1300 XFLOW 1600 XFLOW MODIFIED XFLOW 1600 PINTO 2000 PINTO MODIFIED PINTO CVH ESSEX COLOGNE TRIUMPH A SERIES B SERIES OTHER

MODEL SELECT MODEL P1 B TYPE B+ B+ MALAGA MALAGA MALAGA B+ CANTERA MELOS SIERRA DH SIERRA PU SIERRA EST RICO RICO SHUTTLE BENETO LEGERRA PHAETON S1 PHAETON S2 PHAETON S3 PHAETON S4 SURF COMMANDER LAKELANDER OTHER REG NUM CHASSIS NUMBER ENGINE SELECT ENGINE 1100 XFLOW 1300 XFLOW 1600 XFLOW MODIFIED XFLOW 1600 PINTO 2000 PINTO MODIFIED PINTO CVH ESSEX COLOGNE TRIUMPH A SERIES B SERIES OTHER

MODEL SELECT MODEL P1 B TYPE B+ B+ MALAGA MALAGA MALAGA B+ CANTERA MELOS SIERRA DH SIERRA PU SIERRA EST RICO RICO SHUTTLE BENETO LEGERRA PHAETON S1 PHAETON S2 PHAETON S3 PHAETON S4 SURF COMMANDER LAKELANDER OTHER REG NUM CHASSIS NUMBER ENGINE SELECT ENGINE 1100 XFLOW 1300 XFLOW 1600 XFLOW MODIFIED XFLOW 1600 PINTO 2000 PINTO MODIFIED PINTO CVH ESSEX COLOGNE TRIUMPH A SERIES B SERIES OTHER

MODEL SELECT MODEL P1 B TYPE B+ B+ MALAGA MALAGA MALAGA B+ CANTERA MELOS SIERRA DH SIERRA PU SIERRA EST RICO RICO SHUTTLE BENETO LEGERRA PHAETON S1 PHAETON S2 PHAETON S3 PHAETON S4 SURF COMMANDER LAKELANDER OTHER REG NUM CHASSIS NUMBER ENGINE SELECT ENGINE 1100 XFLOW 1300 XFLOW 1600 XFLOW MODIFIED XFLOW 1600 PINTO 2000 PINTO MODIFIED PINTO CVH ESSEX COLOGNE TRIUMPH A SERIES B SERIES OTHER

UPLOAD PHOTO

FURTHER INFORMATION

Confirmation:

I wish to join the Dutton Owners Club: ______________________________________________

Family members: _______________________________________________________________

All people wishing to join the club must sign above.

If you have previously been a member of the Dutton Owners Club, please indicate here:

Please print this form out, and send together with payment to the Membership Secretary (address at top of page). Your membership pack (including a windscreen sticker and copy of the latest club magazine) will be sent to you shortly, however, please bear in mind that the DOC is run by members in their spare time, so please be a little patient!