CHALMERS AUTOMOBILE REGISTRY

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                        JOIN THE CHALMERS AUTOMOBILE REGISTRY

Joining the Registry for the purpose of simply documenting your Chalmers automobile and
owner data remains no fee.  Please let me know if you desire to be in this category and not
received the newsletter.  See fees at the bottom of the page.  No personal information will be
share with anyone without your permission. 

                                                              Registration Form

(Please fill as information as possible)

 Year___________Model________________________________________________

 

 Serial Number________________________ Engine Number_____________________

 

 Body number________________(Stamped into Seat Frame) Mileage______________

 

Condition (circle one)

(1) Excellent            (2) Very Good           (3) Good           (4) Restorable           (5) Parts

 

Color Body_________________Fender________________Hood__________________

 

Features_______________________________________________________________

 

______________________________________________________________________

 

Missing items and Alterations________________________________________________

 

Current Use (Show-Drive-Tour-Restoring)_____________________________________

 

Previous Ownership History_________________________________________________

 

______________________________________________________________________

 

______________________________________________________________________

 

______________________________________________________________________

  

Name_________________________________________________________________

 

Address_______________________________________________________________

 

______________________________________________________________________

  

Email Address___________________________________________________________

 

Can we email the newsletter?   Yes     No

 

Phone # Home ___________________________Cell____________________________

 

This information is intended for use by the Chalmers Automobile Registry and its

members.  It is strictly forbidding for any other use.

 

Can phone number be listed on membership list to be mailed to current members? 

 

Yes      No

 

Can email address be listed on membership list to be mail to current members?    

 

Yes      No

 

Can address be listed on membership list to be mail to current members?

 

Yes     No

 

Photograph (optional)         Yes       No

 

More information use a separate of paper. 

 

Sign me up for one year newsletter subscription

Enclose $5 US funds cash or check payable to JOE ALACKNESS

Memberships run January 1st-December31st

After September 30 dues will include next year.

Foreign membership $5 by email.  Check with Registry for postal rate.

 

Signature___________________________________________Date________________

 

Email  chalmersregistry@chalmersregistry.com

Web  www.chalmersregistry.com

Snail mail   Chalmers Automobile Registry

                   Joe Alackness

                   908 2nd Ave

                   Royersford, PA 19468 USA