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 :

Licence Plate #

Member of NCM?

Member #

What Corvette Activities
Are You Interested In?

Day Trips

Weekend Trips

4-Day Trips

Poker Runs

 Cook-Outs & More

Other

List Other Hobbies :