NEW MEMBER FORM

 

Input boxes shaded yellow required an entry!

FIRST NAME 

INIT

LAST NAME

SPOUSE NAME

STREET ADDRESS

CITY

 ST

ZIP

HOME PHONE 

BUSINESS PHONE 

FAX

EMAIL ADDRESS

AGE 

OCCUPATION


  

   

How Did You Hear Of Us?  

The code numbers below represent various methods of advertising and local club membership drives. If these numbers mean nothing to you, you have either found us by word of mouth or an internet search. You should use code # 0000.     
Please select the code that directed you to us.

 HEALEYS THAT YOU OWN

If you are the original owner, please check the original owner check box.

 

Scroll down to select

Select your first Car

              

If Other, write in the Model    

Enter serial Number

  Check here if you are the  original Owner

Select your second Car

If Other, write in the Model    

Enter serial Number

  Check here if you are the  original Owner

Select your third Car

If Other, write in the Model    

Enter serial Number

  Check here if you are the  original Owner

Select your fourth Car

If Other, write in the Model    

Enter serial Number

  Check here if you are the  original Owner

Select your fifth Car

If Other, write in the Model    

Enter serial Number

  Check here if you are the  original Owner

Select your sixth Car

If Other write in the Model    

Enter serial Number

  Check here if you are the  original Owner

Select your seventh Car

If Other write in the Model    

Enter serial Number

  Check here if you are the  original Owner

Select your eighth Car

If Other write in the Model    

Enter serial Number

  Check here if you are the  original Owner

Select the AHCA Chapter you wish to join

Please note the amount shown for your selection.  This is the total amount due.   You will enter this amount after you select your payment option.   If you join now, your membership will begin now and continue through the end of this calendar year.