STREET ROD & MODIFIED

SRM

CHAPTER POCI

Steve Cook Treasurer

16565 Lancaster Est. Dr.

Elk Grove, MO 63040

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Name + Spouse Name:___________________________________

Address:_______________________________________________

City/State/Zip:___________________________________________

Tel #:______________________E-mail_______________________

Pontiacs Owned, Year/Model/Style: __________________________

Vehicle Modifications_______________________________________

POCI # _____________(must be POCI member to join)

Please enclose annual dues (June 1 - May 31) of $15