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Mail-In Application

Empire Z Membership Application

Fill-in the Blanks  Applicant Information  Click on Print Form Button Below

First Name:   Last Name: Initial:

Date of Birth:  E-mail:

Phone (Home):   Phone (Cell):

Current Address:

City:   State:   Zip Code:

Car Information - Select from below

Year:      Make:     Model:    Other:

Color:

Associate Membership - (Wife - Son/Daughter - Significant Other)

Name:   Relationship:

Date of Birth:  E-mail:

Phone (Home):   Phone (Cell):

Current Address:

City:   State:   Zip Code:

Emergency Contact - Optional Information

Name: 

Current Address:

City:   State:   Zip Code:

Relationship to Applicant:

Phone (Home):   Phone (Cell):

Membership Fee & Privacy Policy

Membership Fee:  Yearly membership is $35.00 per year - due March 1st.  Dues are $17.50 after September 1st.
Associate Membership Fee:  Yearly associate membership is $10.00 per year - due March 1st.  Dues are $5.00 after September 1st.
Amount Submitted:  
Privacy Policy:  All information submitted on this form will be held confidential by the officers of Empire Z.  Your personal information will not be sold or revealed to anyone without your specific permission.
I hereby state the above information to be true.

Release of Liability

I hereby release Empire Z, its officers and members, from any liability due to accident, injury, theft, or any other reason while attending or participating in any and all Empire Z events and/or functions.  Membership Application is not complete until you have signed the release of liability.

Signature of Applicant: ______________________________________  Date:

Signature of Associate Applicant: _____________________________  Date:

                         Mailing Address:  EmpireZ      P.O. Box 1041    Guasti, CA 91743-1041
You can pay your dues if you have a PayPal account.  Log-in to your PayPal account and make payment to: membership@empirez.com.  Indicate in the Remarks section of PayPal that you are making a payment for dues.  Be sure to print and mail-in your completed application so we know who to apply the payment to.