Membership Type:

Single - $20.00 dues Double - $30.00 dues (spouse/significant other)

(There is a one-time initiation/badge fee of $20.00 for single and $30.00 for double in addition to the regular annual dues.)

Please provide the following information:

State NJ PA DE Other

(include area code)

(include area code)

(include area code)

Corvette #1:

Year 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012     Type Coupe Conv Hardtop

Corvette #2:

Year 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012     Type Coupe Conv Hardtop

Have you ever belonged to a corvette club?

No Yes

If so, name of corvette club.

How did you hear about Lakes Corvette Club?