~ Lakes Region Corvette Club ~ Membership Application

MEMBERSHIP
APPLICATION

To apply for club membership, please
complete the form below and click SUBMIT.

After submitting the application, check your e-mail for a copy. Please print out a copy and mail it with the $35.00 annual dues to :

LRCC
P.O. Box 6362
Lakeport, NH 03247

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

Shows

Rallies

Other

List Other Hobbies :

Vette/Member Photo :

Please select a photo file in JPG, GIF, or BMP format to send with your app.