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Printable Membership Application
International Mercury Owners Association
P.O. Box 1245
Northbrook, IL 60065-1245
Phone: 847-997-8624 Fax: 847-272-1850
E-mail: info@mercuryclub.com

This application is for a New Member     Renewal

If you're a New Member...
How and/or Where did you hear of us? Where you referred by one of our current members? If so, Who referred you?

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I hereby apply for membership in the International Mercury Owners Association (IMOA) Yearly dues are $35.00 US funds for Continental US & Canada ($40.00 US funds elsewhere). Dues paid will automatically give you membership in the regional IMOA in your area (where applicable).

Please charge my:

MasterCard   Visa  Discover  American Express
Credit Card #:____________________________________
Expiration Date: _______/_________

IMOA is authorized to charge my account a total of $______

Cardholder Signature_______________________________________
Your signature authorizes us to charge one year of IMOA dues. This information is kept private.

- OR -

Check or Money Order payable to I.M.O.A.

Address envelope to:
     Jerry Robbin
     International Mercury Owners Association
     P.O. Box 1245
     Northbrook,IL 60065-1245

Member Information

Name_________________________________________________________

Occupation____________________________________________________

Address_______________________________________________________

Date of Birth_________________________________________________

City__________________________________________________________

State_________________________________________________________

Zip___________________________________________________________

Phone#(include area code)_______________________________________

E-mail ________________________________________________________

Marital Status: ______ Single ______Married ______Other

Spouse's Name:__________________________________________

Tell us about your Mercury(s)

Mercury 1
Year____________________________________________________
Model___________________________________________________
VIN____________________________________________________
Condition________________________________________________
Color____________________________________________________


Mercury 2
Year____________________________________________________
Model___________________________________________________
VIN____________________________________________________
Condition________________________________________________
Color____________________________________________________


Mercury 3
Year____________________________________________________
Model___________________________________________________
VIN____________________________________________________
Condition________________________________________________
Color____________________________________________________

Please enclose with this application

  • Photos of your Mercury(s) (Enclose a SASE for photo returns)
  • Any technical tips you may have to share with our members
  • Ads you would like placed (free of charge to members)
  • Articles you have written so that we may include them in the next edition of our publication, Quicksilver.

Thank you for becoming a proud member of
the International Mercury Owners Association
and your local region of the IMOA !