NAME              __________________________________________________


HOME ADDRESS      __________________________________________________


CITY, STATE, ZIP  __________________________________________________


HOME PHONE #      __________________________________________________


WORK PHONE#       __________________________________________________


FAX#              __________________________________________________


FORD INTER-CO ADDRESS        _______________________________________


PROFS ID OR E-MAIL ADDRESS   _______________________________________


      BREWING LEVEL:           BREWING STYLE                     
      ___ BEGINNER              ____ EXTRACTS                   
      ___ INTERMEDIATE          ____ PARTIAL MASHES             
      ___ ADVANCED              ____ ALL GRAIN                  


Specialties?  (kegging,  yeast culturing, mead, lambics,   
hop farming, judging, pico brewing, ciders)

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Please select one of the following:   I am a..........    
   (FOR INTERNAL USES ONLY!)

Ford Employee   ______   Ford Contract _____

A-Plan eligible ______   Other         _____ 


Do you have MS Word and Netscape at work? (Ford Only) Yes __ No __                        
  
Office Use Only...

Dues Paid     _________________    Member Number________________

T-Shirt Size? _________________    Picked Up    ________________