Custom Safari Chapter Renewal Form 2004

Please print clearly or type.

Name		Spouse 		
Address	
City		State		Zip	
Country		Phone		
Email		POCI #			

In order to update the chapter’s records, we’d like to know the style, body number, trim, paint, and accessories codes for your Safaris. This information can be found on the firewall data plate. Additional Safaris may be listed on the back of this sheet. Include a recent photo of your Safari or email a photo to rpye@rochester.rr.com  Update the form on the back if you have not been a “Safari Member of the Quarter.”

STYLE	BODY NO.	TRIM	PAINT	ACC	

					

Dues are $18.00 per year. 
Please make check payable to Custom Safari Chapter, POCI. 
Mail to:  Starr F. Evans, 10 Church Hill Road, Washington Depot, CT 06794

Annual dues are payable each January. The Custom Safari Chapter issues the Safari News four times per year. Each issue contains 12 or more full-color pages of information about the chapter and 1955-57 Safari wagons.