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u u ,CORVETTE CLUB

CHARLESTON. WV -

Kanawha Valley Corvette Club

The Oldest Corvette Club in West Virginia

____L_L_MembershiAlication

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Spouse/Comm1'on.'

Phone.‘

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beof Conette

Year/s.'Color.-Bow Style.-Engl'ne.'

m'scellmeous Interest.-Cm1’ses/Tous.'Soc1'al Act1'v1't1'es.‘Autocrosses.'Car Shows.-Ralll'es/Econow Rms.'

Date Jal'ned.'

Charles Stephens, WCC Govemorm;‘1.— gstehecr2@w1’natrem.net

Send Cowleted Fom & fleck To.-Pegg Stephens, WCC Treasurer54521 State Route 681Ree®v1'lle, OH 45772-9073m;’l.- @3tehecr28w1‘nfitrem.net

Cell Phone.-

Wmt Pal'd.'

Inl'tl'al Mmershl'p Wes.' $45.00Prm'q Renewal Wes.“ $35.00

$0use/Comm1'on.' $20.00We check pay$le to.-

Kanawha Valley Conette Clw

wpll'catl‘on Rev1'sed.' 09-01-2017

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NCCC Membership ApplicationPlease print or type all infonnation.

Club Affiliation:Male:

Female: NCCC #Male:

Female: NCCC#Male:

Female: NCCC #

Primary:

Spouse/Companion:

Youth:

Youth’s Date of Birth:Youth’s Primary NCCC #

Address:

City State&Zip:

Email Address:Email Address:Email Address:

Primary: Phone #:Spouse/Companion: Phone #:Youth: Phone #:

__—pLevelsof Mem bershi

Primary $35.00 (New or Late Renew)Spouse/Companion $ 10.00

Youth $ 10.00 (16-21 years old under the Membership of a Primary Member)Lifetime Member $335.00 (one time charge)Member-at-Large Primary $35.00 (Not in an NCCC Corvette Club at this time)Member—at—Large Spouse/Companion $10.00 (Not in an NCCC Corvette Club at this time)Associate $35.00(fill—in primary information above, former NCCC member without Corvette or club)Enthusiast $35.00 (New)

Transfer from club #Change of name, address, or car (circle change(s)Previous NCCC Member NCCC# What year?

Corvette Information

Coupe, Convertible, Fixed Roof, 206, or ZR] (circle one)Year:

Applicant Signature(s): 3___________________ Date:

Date:X

This certifies that I am at least 16 years of age.

The annual pn‘mary dues for NCCC membership includes $10.00 for a one-year subscription to the NCCC BlueBars publication. These dues are for the year

Date:RMD Initials:

Revised 20-Apr—20] 6

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