New Member Registration Form

Membership Information
First Name: Last Name: Date Of Birth:
Address: Phone #:
City: State: Zip Code:
E-mail: Fax #:

Co-Pilot Information (If Applicable)
Full Name: Date Of Birth:
Address: Phone #:
City: State: Zip Code:
E-mail: Fax #:

Vehicle Information:
Year: Make: Model:
Color: Tire Size: Lift:
Other Modifications:
License Plate: Vin #: Drivers License #:
Insurance Carrier: Policy#:
Membership Fees:
Membership Fees are not paid until your truck is judged. After you submit this form you will be contacted to arrage for your vehicle to be judged and at that time you may pay for membership.
1 Year Membership: $30.00 (includes rear window decal)
1 Year Auxiliary Membership: $15.00 (includes rear window decal)
** You must be 18 years of age to qualify for membership. Those under the age of 18 must sign up as a co-pilot with a parent or guardian.
** For those that do not meet the criteria for regular membership. (fill out the top portion of the form only)
** Members are required to display a High Rollers 4x4 Club windshield decal on truck at all shows. If you are interested in purchasing a windshield decal or additional rear window decals , please contact Mark Zanni, President at(856)697-8963 or e-mail him at optiwizard@cccnj.net for order form and color chart.