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