MEMBERSHIP APPLICATION
(Please Print)

An affiliate of the Rolls-Royce Owners' Club, the Derby Bentley Society is a non-profit organization formed to stimulate interest in the preservation, restoration and touring of Derby Bentleys. Ownership of a Derby Bentley is not required: A sincere appreciation of the Marque is sufficient. Current membership in the RROC is required for North American applicants only.

Name(last, first):________________________________ Spouse/Partner:_______________

Address:________________________________________________

City:__________________________ State:____________ Zip:___________

Phone - Home:(____)______________ Office:(____)_____________

Fax:(____)________________ Email:___________________

Year	Model	Chassis #	Engine#	. . . Coachbuilder . . .	. . . Body Style . . .	Body #	UK License#
.	.	.	.	.	.	.	.
.	.	.	.	.	.	.	.
.	.	.	.	.	.	.	.

Dues Information:

Annual Dues	. $30.00
	.
Spouse ($1.00-optional)	. ______
Total	$_______

Signature:________________________________ Date:_______________

Please make your check/money order payable in U.S. dollars to:

"The Derby Bentley Society"
Mail to: Derby Bentley Society, c/o Martha Kushner- Membership Chairman,
100 Ravinoaks Lane, Highland Park, IL 60035 USA

Payment Type:
Check/Money Order ____ - ...MasterCard ___ - ...Visa ___ - ...Cash ___ - ...

Total $ _________

Account No. _______________________ Exp. Date_______ Auth Signature___________________