Lakes Region Corvettes
Membership Application

Name: 
Street Address: 
City: 
State: 
Zip Code: 
Date of Birth: 
Home Phone #: 
Business Phone #: 
E-Mail Address: 
Fax No.: 
Year of your Corvette: 
Color: 
Style: 
Plate: 
List your hobbies: 

Describe your car: Original Restored Custom

Have you ever been a Corvette club member? No Yes If so, which club?










What Corvette activities are you interested in?
Shows
Rallies
Drag Racing
Auto-X
Weekend Trips
Long Event Trips
Parties

A picture of your car should accompany your check for your annual dues
$25.00



Please make check payable to:

Lakes Region Corvettes
PO BOX 6362
LAKEPORT, NH 03247-6362


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copyright 1998, 1999
Last Update: 6-04-00