NORTHSHORE CORVETTE CLUB
c/o Dusty Portie, Membership Administrator
160B Lakeview Drive
Slidell, LA 70458
www.northshorecorvetteclub.com
____MEMBERSHIP ____RENEWAL
(Please Print or Type)
AN EMAIL ADDRESS IS VITAL, AS NEWSLETTERS & MESSAGES ARE SENT ELECTRONICALLY
LAST NAME:________________________________FIRST NAME:____________________________M.I._____
ADDRESS:___________________________________________________________________________________
CITY:_____________________________________STATE:___________ZIP CODE:________________________
BIRTHDATE
(Mo/Day/Year):___________________
CONTACT INFORMATION (Include Area Code in ALL Telephone Numbers Listed Below)
HOME:________________________________________ CELL:____________________________________
E MAIL ADDRESS:____________________________________________________________________________
SPOUSE / ASSOCIATE INFORMATION
NAME:_____________________________________BIRTH DATE(Mo/Day/Year):____________________________
CELL:_________________________________________
EMAIL ADDRESS:_____________________________________________________________________________
CORVETTE INFORMATION
YEAR:__________ BODY STYLE:_______________________ COLOR:_________________________________
YEAR:__________ BODY STYLE:_______________________ COLOR:_________________________________
INTERESTS (other than Corvettes):________________________________________________________________
MEMBERSHIP DUES: $100.00