Membership Application Form (World Wide)

Type in your information, print the form and return to us at;
Mercedes-Benz Owners, Langton Road, Langton Green, Tunbridge Wells, Kent, TN3 0EG, ENGLAND or fax to; 0044 (0)1892 861363


YOUR DETAILS

Name:

Address:


Town/City:

County/Province/State:

Post Code/Zip:

Day time Telephone:

Email Address:
YOUR VEHICLE DETAILS

Mercedes Model:

Year:

Owned Since:

Do you service your car yourself? YES NO

If no, please give the name and address of the garage:
Payment by Credit Card

 Select as appropriate:
1 year Please charge my credit card for £60 (price is for World Wide membership only)

Credit Card Number:

Issue Date:
- -
Expiry Date:
- -

Signature:

Date:
 - -
Switch Issue Number:
Security Number last three digits on back of your card:

Please ensure that you have signed where applicable
© 2007 Mercedes-Benz Owners