STREET ROD & MODIFIED

SRM

CHAPTER POCI

Charlie Huntington Treasurer

78 Lynch Rd

Newcastle, ME 04553

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Name + Spouse Name:___________________________________

Address:_______________________________________________

City/State/Zip:___________________________________________

Tel #:______________________E-mail_______________________

Pontiacs Owned, Year/Model/Style: __________________________

POCI # _____________(must be POCI member to join)

Please enclose annual dues (July - July) of $15