Last name______________ Name____________________
DOB Month_____ Day______
Wife's name_________________ DOB Month______Day____
Address_______________________________________
_____________________________________Fl. 33_____
Anniversary date Month_____ Day______
Phones: Home_________________ Office_____________
Cel_________________ Fax____________________
Profession: ____________________
Antique cars you own: Thunderbird yr ________
Others__________________________________
Please mail with check for $35.00 to:
Felipe Cos
4000 Monserrate St. Coral Gables, Fl. 33146
