Tidewater Mopar Club Application

Please complete the following information out completely to joinTMC!

Personal Information:
Full Name of Card Holder As It Appears On The Credit Card (ex. John P. Smith)
Billing Street Address of Card Holder (ex. 1234 Elm St.)
City Address (ex. Your City)
State Address (ex. Your State)
Zip Address (ex. Your Zip)
Phone Number (ex. 123-456-7890)
Email Address (ex. name@domain.com)
Do You Wish To Receive Weekly Emails From TMC

Information About You & Your Vehicles
Spouse Name (ex. Jane S. Smith)
Work Phone Number (ex. 123-456-7890)
Your Birthdate (ex. mm/dd/yyyy)
Spouse Birthdate (ex. mm/dd/yyyy)
If Married Anniversary Date (ex. mm/dd/yyyy)
Type of Business or Occupation You Are In (ex. employer)
List Any Other Clubs That You Are Involved In (ex. National Drag Club Association)
How Did You Hear About Tidewater Mopar Club
To help us better organize and make the most from our advertisements, please state where you heard about our Annual Charity Give-away.

Below List all vehicles you own for hobby or general transportation use:

(YEAR MAKE MODEL COLOR CONDITION ENGINE)

Club dues are $20.00 a year! All memberships expire on December 31st of each year. Club dues will be due starting January 1st of each year!

Credit Card Information:
Select Type of Credit Card Being Used
Credit Card Number (4011012345678900)
CVV Number
This is the 3 digit number located on the back of your card that follows the last 4 digits of your credit card number (Visa and Mastercard only) or the 4 digit number on the back of your American Express. If you are unsure what it is, contact your credit card institution before continuing. If your credit card institution stated that they do not issue these numbers, answer N/A above. If you answer N/A and authorization comes back that a CVV was issued, your order will be rejected.
Expiration Date (mm/yyyy)

Please review this form for accuracy before submitting. For security purposes, your remote address and user agent are traced through submission.

By submitting this form you are confirming that you have read in full, understand, and agree to adhere to our policies.

By submitting this form you confirm that you are the authorized user of the above credit card and authorize Tidewater Mopar Club Inc. to charge your credit card for this transaction.

NOTE: Tidewater Mopar Club Inc. will be the name that will appear on your credit card/banking statement.

By clicking "Accept" below you agree to the following terms and conditions. Sorry there are no returns or exchanges due to the fact all proceeds will be going to designated charities. For further information or Customer Service contact Tidewater Mopar Club Inc.'s President at (757) 248-5971 or emailing him at tmc.pres@tidewatermoparclub.com. All transactions must be completed in US Currency. Please allow up to 2 weeks for returned receipt stub and membership package will be mailed out within 2-3 weeks.

(Please press Accept only once or you will be charged mulitiple times)
Just as a reminder, we believe in your privacy so the information will be sent to a secure server for credit card processing.