LAKES REGION
CORVETTE CLUB

MEMBERSHIP
APPLICATION

Primary Member

  

First & Last Name :

D.O.B. / /

Address :

City :

State : Zip : Country :

Home Phone :
( ) - -

Cell Phone : ( ) - -

E-Mail :

Spouse / Sig. Other

  

First & Last Name :

D.O.B.

Anniversary Date :

 / /

Corvette Information

 

Year :

Body Style :

Color :

License Plate #

Engine :

HP :

Trans :

Member of NCM?

Member #

Own a brick?

What Corvette Activities
Are You Interested In?

Long Trips

Weekend Trips

Drag Racing

Auto-X

Parties

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Other

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