Porsche Club of America, Connecticut Valley Region
Membership Application
*= Required Information
This Section Will Be Forwarded To The PCA Executive Office Please TYPE or print in BLOCK LETTERS
 
Name * 
Street * 
  City * 
St *   Zip Code * 
County * 
 
** Family Member 
Relationship 
** Affiliate Member 
**NOTE: Member may name either Family or Affiliate; NOT Both. Family or Affiliate member must be 18 years or older.
 
Porsche Information:*
Model *   Year * 
Serial No. * 
Local Region CONNECTICUT VALLEY
 
I own, (co-own) a Porsche, am 18 years of age or over, and having read the Objectives of PCA herewith apply for Active Membership in the Porsche Club of America.
 
Visa/MC#   Exp.Date 
Name as it appears on card
___________________________________
Signature and Date)*
ENDORSEMENT BY REGION OFFICIAL
This application MUST be processed through a local PCA Region and must be endorsed by a Regional Officer
Signed ____________________
Title _____________________
Region CONNECTICUT VALLEY
Date __________
For Executive Office Use Only
Date Processed ____________________
Panorama Code ____________________
Card Expiration ____________
MO Check MC AMT ____________
VISA ____________________
This Section Will Be Retained by Your Local PCA Region. Please TYPE or print in BLOCK LETTERS
 
Name * 
Street * 
City * 
St *   Zip Code * 
County * 
 
E-mail Address 
May we use your e-mail address on the Website?
 Yes: No:
 
** Family Member 
Relationship 
** Affiliate Member 
**NOTE: Member may name either Family or Affiliate; NOT Both. Family or Affiliate member must be 18 years or older.
 
Porsche Information:*
Model *   Year * 
Serial No. * 
Body Type * 
Color * 
Local Region CONNECTICUT VALLEY
Car Used: Daily  For Pleasure
 
PCA REGIONAL ACTIVITY INFO:
Age   Occupation 
Tel. No. 
Single   Married 
Spouse's Name 
Name & Ages of Children
My Interests are: (check all that apply)

Technical Social Concours Autocrossing Rallying Driver's Ed

 
Porsche Maintenance is performed by:
Self   Dealer   Independent 
 
FOR PCA REGION USE ONLY:
Date Processed __________________
Amount Paid in U.S. Funds $__________
Check___ Cash___ MC___ VISA___
Send via mail to: Paul Greenburg - Membership Co-Chairman, 30 Owenoke Park - Westport, CT 06880-6832, with your $42.00 check payable to "PCA," if applicable.