(Membership dues $5.00 ) (plus $10.00 for back newsletters if desired, & another $2.00 for foreign addresses)to: Dave Baas 7058 Plum Creek Dr. Sellersburg, IN.47172 Phone: 812-248-0565
Last Name: ____________________ First Name: ______________________
Address: _________________City: _____________State: ___ Zip: _____
Area Code: ________Telephone #:________________
E-Mail _______________________Verify E-Mail_______________________
Newsletter sent by E-Mail only.
Occupation: ________________________Date of Birth:____/____/_____
Member of Local Chapter # __________Chapter Location:_______________
Gibson #1: Tractor Model: ____Circle 22" or 24" rear tires,(if model D)
Tractor Serial #: __________________(stamped into top right or left front rail or front top angle lip)
Engine brand: _____________ Model: ___________ Serial #: ______________
Gibson #2 Tractor Model: ____ Circle 22" or 24" rear tires,(if model D)
Tractor Serial #: __________________Engine brand: ________________
Model: _______________ Serial #:______________________
Gibson #3: Tractor Model: ____Circle 22" or 24" rear tires,(if model D)
Tractor Serial #: _________________Engine brand: _________________
Model: ________________ Serial #:_____________________
Comments: (List additional tractors, what paint used (attach color photos for club album), names & addresses of prospective members, etc. Make sure you include your E-Mail address. Newsletter sent by E-Mail only. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
Office use: rec'vd: ____/_____/______ m#: ____
