| 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 (first,last) |
_________________________________________________________________________ |
| Spouse/Partner |
_________________________________________________________________________ |
| Address |
_________________________________________________________________________ |
| City |
__________________________________________ |
State |
__________ |
Post Code |
_________________ |
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| Phone:
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Home |
( )
______________________ |
Work |
( )
______________________ |
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| Fax |
( )
______________________ |
Email |
__________________________________________________ |
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| Year |
Model |
Chassis# |
Engine# |
Coachbuilder |
Body
Style |
Body# |
UK
License# |
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Dues Information
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Annual Dues |
$30.00 |
| Spouse ($1 -
optional) |
______ |
| Total |
$ |
|
| Signature |
____________________________________________ |
Date |
______________ |
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| Payment Type: |
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| Check/Money
Order |
_____ |
MasterCard |
_____ |
Visa |
_____ |
Cash |
_____ |
| Total
$__________ |
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| For a check,
please make payable to "The Derby Bentley Society" |
| |
| For a credit
card, please provide the following: |
| |
| Account No. |
__________________________ |
Exp. Date |
__________ |
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| Auth
Signature. |
__________________________ |
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| Mail To: |
| Derby Bentley Society |
| c/o Martha Kushner-
Membership Chairman |
| 100 Ravinoaks Lane |
| Highland Park, IL 60035 |
| USA |
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