Connecticut Cougar Club Registration Form

The Following is a registration form for the Connecticut Cougar Club, please fill it out completely. You may fill it
out online, then print and sign it. We are currently in the process of making this form available to submit online, however,
we are having difficulties, so please disregard the submit buttons on bottom of page. To print, go to the FILE menu and
select print.

You will need to make a check or money order in the amount of $12.00 for annual dues, made out to The CT. Cougar Club and send it to:

Mark Nettleton
110 Bayberry Ln
Meriden, CT 06450
phone 203-237-7787

MN73cougar@aol.com

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Please provide the following contact information:

Name

Address

City and State

Year and Model

Carb 2V or 4V

Work Phone

Home Phone

FAX

E-mail

Vehicle ID # WARRANTY NUMBER

BODY COLOR

TRIM AXLE

TRANS DSO

Not for title or registration

Please check original options:

Vinyl Roof               Conv.Top                Decor Group 

Bumper Guards            Door Edge Guards        Curb Moldings 

Sunroof                  Floor Mats              Deluxe Seat belts

Rim Blow steering Wheel  Deluxe Seat belts w/ shoulder straps

Deluxe Wheel Covers      Styled steel wheels     Deluxe wheel covers w/ spinners

Wire Wheel Covers        LH remote control Mirror

LH rem. ctl racing mirror Interval wipers        Tinted glass

Visual Check panel       Rear Windows defogger   Dual Exhaust

Heavy Duty battery       Traction lock axle      Detroit locker

GT option Pref. handling package 

Drag pak opt.            Ram air                 Seat back rel.

Console                  Bench seat              Tilt wheel 

Speed control            Courtesy lights         Clock

Comfort stream vent.     Air Conditioning        AM Radio 

AM/FM Radio              AM/FM stereo            AM/Stereo Tape

Rear Speakers            Power brakes            Power disk brakes

Power steering           Power windows           Power seat

F70x14        F78x14 wsw       F70x14 wsw         F70x14 belted wsw

Space saver spare        3-spd manual            3-spd heavy duty 

4-spd close ratio        4-spd wide ratio        C-4 auto

C-6 auto                 FMX auto                Eliminator opt.

Competiton Handling package                        Super drag pak opt.

Other options not listed above

I give my permission for the following to appear on the CT. Cougar Club Roster.

NAME      Yes     No

ADDRESS   Yes     No

PHONE     Yes     No

Do you mind having your Cougar entered in a national database to determine how

many Cougars are in existence? Yes No

If no, can existence of your Cougar be noted? Yes No

YOUR SIGNATURE

Name
Address
City and State
Year and Model
Carb 2V or 4V
Work Phone
Home Phone
FAX
E-mail

Connecticut Cougar Club Registration Form

All info is kept in strict confidence by the CT. Cougar Club Last revised: February 19, 2005

All info is kept in strict confidence by the CT. Cougar Club
Last revised: February 19, 2005