Please Print & Complete This Form

Membership Application

Please mail or (e-mail to the Secretary) this application, along with a check
for $35 to the below address

If Available send an e-mail photo of each car to LRCorvetteclub@ aol.com

Lakes Region Corvettes

P/O Box 6362

Lakeport, NH 03246-6362

First & Last Name(s): __________________________________

Street: ____________________________________________City: _________________ State: ________ ZIP: __________

Date(s) of Birth: ______________________________________

Anniversary Date: ____________________________________

Home Phone #: ______________________________________

Cell Phone #: ______________________________________

E-Mail Address: ______________________________________

Member NCM?:____ Member#___________  Own a Brick?_____                 Individual ____   or  Family____

Year of Your Corvette: ________ License Plate: ____________

Color: ________________ Body Style: _________________

Have you ever been a Corvette club member? __Yes __No

If Yes, which club: ________________________________

What Corvette activities are you interested in?

__Shows __Rallies __Drag Racing __Auto-X

__Parties __Long Trips __Weekend Trips

__Other:________________________________

List Your Other Hobbies:_________________________________

_______________________________________________________