Date: ___________________________

Name: __________________________                Spouse: _________________________

Address: ________________________                Home Phone #: ___________________

City: ___________________________                Cell Phone # _____________________

State: _____________ Zip: _________                Email Address: ___________________

============================                ============================

Corvette(s) you own:

(Year) (Color) (Coupe or Convertible) (Stock or Modified)

(Year) (Color) (Coupe or Convertible) (Stock or Modified)

(Year) (Color) (Coupe or Convertible) (Stock or Modified)

Agency with whom your vehicles are insured: ____________________________________

Applicant’s Signature: __________________________ Sponsored by: ______________

Dues prorated as follows: Join Jan – Mar: $35.00

Apr – Jun: $26.25

Jul – Sep: $17.50

Oct – Dec: $ 8.75

For more information contact:

Todd or Cheryl (270) 247-1050 or email: unek98@galaxycable.net

Keith or Mary Lou (270) 753-8008 or email: ckbud@email.com