Date: ____________

        Print the following:

        Primary member:________________________

        Spouse: _______________________________

        Address:_______________________________

                     _______________________________   

       zip code: ___________

       Telephone number(s):__________________

                                       __________________

       E- mail: ____________________________

       Fax: _______________________________

      Corvette(s) owned (color, model, year):

       ___________________________________

       ___________________________________

       ___________________________________