OWNERS :  __________________________________________________________

VEHICLE-Year,Make,Model : __________________________________________

ENGINE : ___________________________________________________________

INDUCTION : ________________________________________________________

CAMSHAFT : _________________________________________________________

IGNITION : _________________________________________________________

EXHAUST : __________________________________________________________

TRANSMISSION : _____________________________________________________

CONVERTER : ________________________________________________________

REAR AXLE : ________________________________________________________

FRONT SUSPENSION : _________________________________________________

REAR SUSPENSION : __________________________________________________

WHEELS/TIRES : _____________________________________________________

INTERIOR : _________________________________________________________

GAUGES : ___________________________________________________________

BODY : _____________________________________________________________

PERFORMANCE : ______________________________________________________

PHOTOGRAPHER : _____________________________________________________
REMARKS AND/OR STORY : 

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I give MID-MICHIGAN MOPAR ENTHUSIASTS permission to publish
information and accompanying photographs ;

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Dated : _______________________