NAME: VTCI #

MAIL ADDRESS:

CITY - STATE /PROVINCE - ZIP:

COUNTRY:   PHONE:

E-MAIL ADDRESS:

Payment enclosed. Please make check payable to: Vintage Thunderbird Club International

Please mail to:
VTCI Country Store c/o Marilyn Paliani
1304 Greenwood
Schertz, TX 78154

or fax order with credit card # to 210-566-8874
Visa or Mastercard # ONLY

Expiration Date

Signature_________________________________________________