Primary: Mr/Ms__________________________________________________________

     Spouse/Companion: Mr/Ms_________________________________________________

     Dependent: Mr/Ms________________________________________________________

     Print your address: ________________________________________________________

     Print your City: ___________________________________________________________

     Print your State: _________ Print your Zip Code______________ -__________

     Print your Phone Number:(____)____________ Fax Number:(____)__________

     E-mail Address: _________________________________

     Are you in a Corvette Club?

     If yes, which Club?__________________________________

     Levels of Membership:

     ______ New NCCC Membership: $35.00 Primary

     ______ Spouse/Companion NCCC Membership: $10.00 Spouse/Companion

     ______ Dependent: $10.00 (16-21 years old under the Membership of a Primary Member)

     ______ Lifetime Member: $335.00 (one time charge)

     ______ Member At Large (Not in an NCCC Corvette Club at this time)

     ______ Previous NCCC Member? Year: _____________________

     ______ Change of address

     ______ Transfer from another NCCC Corvette Club
                         (If transferring, what was your old NCCC number?: _______________)