COMPLETE THIS FORM AND MAIL TO:
RON CROUCH
CCOA MEMBERSHIP DIRECTOR
1637 SKYLINE DRIVE
NORFOLK, VA 23518-4327
NAME:_________________________________________ CCOA MEMBERSHIP #:______________
ADDRESS:______________________________________ ORIGINAL OWNER?_________________
CITY:________________________STATE:___________ WINDOW STICKER / INVOICE?_______
ZIP CODE:____________PHONE:___________________ MILEAGE:________________________
Warranty Plate Information: (found on Driver's door)
______________________________ DATE _____
WARRANTY NUMBER (11 DIGITS) VEH.IDENT.NO.______________ BODY___ COL____
____ _____ ____ ____ ___ ____ _____ TRIM_____ AXLE_____ TRANS_____ DSO_____
BODY COLOR TRIM DATE DSO AXLE TRANS
For 1967 - 1969 Cougars For 1970 - Newer Cougars
PLEASE CHECK ALL ORIGINAL OPTIONS:
Models Exterior Interior
[ ] Standard Coupe [ ] Vinyl top : Color________[ ] Decore Group
[ ] XR7 Coupe [ ] Conv. top : Color _______[ ] Tilt- Away Steering Wheel
[ ] Convertible [ ] Sunroof [ ] Tilt Steering Column
[ ] XR7 Convertible [ ] Front Bumper Guards [ ] Rim Blow Steering Wheel
[ ] Dan Gurney Special [ ] Rear Bumper Guards [ ] Speed Control
[ ] XR7-G [ ] Door Edge Guards [ ] Console
[ ] 6.5 Litre [ ] Curb moldings [ ] Clock
[ ] GT Performance Option [ ] L.H. Rem. Control Mirror [ ] Visual Check Panel
[ ] GTE Performance Option [ ] L.H. Rem. Control Racing [ ] Bench Seat
[ ] Eliminator [ ] R.H. Sport Mirror [ ] Floor mats
[ ] Sports Special [ ] Styled Steel Wheels [ ] Courtesy Lights
[ ] Other _________________ [ ] Deluxe Wheel Covers [ ] Comfort Stream Ventilation
[ ] Dlx Whl Covers w/Spinners[ ] Air Conditioning
[ ] Wire Wheel Covers [ ] Tinted Glass
Overall Condition * [ ] Space Saver Spare [ ] Front Seat Headrests(68 only)
[ ] 1 - Excellant [ ] F70x14 [ ] Seat Back Releases
[ ] 2 - Fine [ ] F78x14 wsw [ ] Deluxe Seat Belts
[ ] 3 - Very Good [ ] F70x14 wsw [ ] Dlx Seat Belts w/shldr straps
[ ] 4 - Good [ ] F70x14 belted wsw [ ] Rear Seat Shldr Belts(68only)
[ ] 5 - Restorable [ ] Other _________________ [ ] Rear Window Defogger
[ ] 6 - Junkyard/Parts Car [ ] Rear Window Defogger
[ ] PS - Parted & Scrapped [ ] Interval Wipers
Handling Options [ ] Power Windows
[ ] Drag Pak Option [ ] Power Seat (s)
Engine Area [ ] Super Drag Pak Option [ ] Power Steering
[ ] Ram Air [ ] Performance Handling Pkg [ ] Power Disc Brakes
[ ] Dual Exhaust [ ] Competition Handling Pkg [ ] Power Drum Brakes
[ ] Heavy Duty Battery [ ] 351 Performance Option [ ] Other _________________
[ ] 289 - 2V [ ] Other _________________
[ ] 289 - 4V Audio
[ ] 302 - 2V Transmission [ ] AM Radio
[ ] 302 - 4V [ ] C-4 Auto Transmission [ ] AM / FM Radio ('67 only)
[ ] BOSS 302 [ ] C-6 Auto Transmission [ ] AM / FM Stereo
[ ] 351 - 2V __W __C [ ] FMX Auto Transmission [ ] AM / Stereo Tape
[ ] 351 - 4V __W __C [ ] 3-speed Manual Trans. [ ] Kick Panel Speakers
[ ] 351 CJ [ ] 3-speed Heavy Duty Trans.[ ] Rear Speaker (s)
[ ] 390 - 2V [ ] 4-speed close ratio Trans.
[ ] 390 - 4V [ ] 4-speed wide ratio Trans.
[ ] 427 - 4V [ ] Other _________________
[ ] 428 - 4V __CJ __SCJ Rear Axle _______________________
[ ] 428 CJ [ ] Traction Lok Axle _______________________
[ ] 429 - 4V __CJ __SCJ[ ] Detroit locker _______________________
[ ] Other _________________ [ ] Axle ratio _____________ _______________________
The following is an abbreviated explanation of the condition categories courtesy of the
Old Cars Price Guide. This is the most commonly used condition numbering system for grading a car's condition.
(#1) Excellent: Restored to current maximum professional standards of quality in every area, or a perfect original with components operating and appearing as new. A 95-plus point show car that is not driven.
(#2) Fine: Well-restored, or a combination of superior restoration and excellent original. Also, an extremely well-maintained original showing very minimal wear.
(#3) Very Good: Completely operable original or "older restoration" showing wear. Also, a good amateur restoration, all presentable and serviceable inside and out.
(#4) Good: A driveable vehicle needing no, or only minor, work to be functional. Also, a deteriorated restoration or a very poor amateur restoration.
(#5) Restorable: Needs complete restoration of body, chassis and interior. May or may not be running, but isn't weathered, wrecked and/or stripped to the point of being useful only for parts.
(#6) Parts Car: May or may not be running, but is weathered, wrecked, and/or stripped to the point of being useful primarily for parts.
(PS) Parted & Scrapped: Gone to Cougar Heaven. (Not from OCPG, but our addition for database purposes)