NSX Club of America Membership Registration Form

Annual NSXCA membership dues: $40.00 US

Voluntary $60 contribution to the Florida Chapter

Total $100 (please specify $40 dues, $60 contribution in memo section of check)

make check payable to "NSX Club of America, Inc."

mail to NSXCA, c/o Wei-Shen Chin, 322 E. Central Blvd., #1502, Orlando, FL  32806

Name:________________________________________

Address:_______________________________________

City, State, Zip__________________________________

Home phone____________________

Work phone_____________________

FAX________________________

email_______________________

NSX model year______________________

manual _____   automatic ______

coupe_____  NSX-T_______

exterior color_______________

interior color_______________

VIN#_______________________________________

special interests: (circle those that apply)

autocross, time trials, road course events, road rally, aftermarket performance, concours, social gatherings, car care and maintenance, model cars, other__________________________________________________

How did you hear about the NSX Club of America (circle those that apply)

in the mail, internet mailing list, dealer, NSXCA member, Acura Style magazine, the internet web site, other__________________________________________