Form No: KPC 1-A

Rev. : 1a
Revision Date : 10/2/2008
Effective Date : 10/2/2008
Pls attach 1x1 ID photo on this side
Club website:
Look for Local Chapters/Cebu Chapter Sub-board
Car Club Membership Form
Family Name: Date:
First Name: Nickname: Forum Username:
Middle name Birthdate:
LTO License No. Birthplace:
Complete Address:
Zip Code:
Email Address:
Home Tel. Number: Mobile Number:
Office Address:
Office Tel. No.: Office/Home Fax No.:
Occupation: In the field of:
Business (if any):
Skills/Expertise:

Vehicles owned:(current) (make,model,year) (plate number) (fuel)

What are your interest: (check as many as you wish)

Car Maintenance Drag racing Others:____________________

Car Modification/Tuning Autocross ________ ____________
Restoration Drifting ________ ____________
Car Audio Enthusiast Rally ________ ____________
Car Show Roadtrip
Social
Any Notable Hobbies, other interest,etc:

If a member has a car problem near you can you offer Roadside Help/Assistance?
Please check:
Yes No
If YES, when wouldn't you mind being contacted:
Days Evenings Nights Weekends Past 12MN or early morning
Please provide youre preferred contact number for this purpose:

In case of emergency please notify the following contact persons below: Name & contact no.

The undersigned is a bonafide member of the Kia Pride Club Cebu Chapter and entitled to all rights and
privileges due to a member.
Signature over Printed Name

EB's attended:_______________ Verified by: