(PLEASE PRINT)                                                     Date :  ____________

Name :  _____________________________________________________

Address :  ___________________________________________________

City :  ___________________________  State :  ______  Zip :  _________

Home Phone :  _____________________  Cell Phone :  _______________

E-Mail :  _____________________________________________________

Type of Corvette (s) owned : 

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Interests :          Shows  _____          Racing  _____          Cruising  _____

                              Other  ___________________________________________

Fee Schedule :                        Couples                   Individuals                  Associate

Annual Dues :                          $30.00                       $20.00                         $10.00

Please remit a check or money order in the appropriate amount to :

                          LEBANON AREA CORVETTE CLUB

                          P O BOX 526

                          JONESTOWN   PA    17038