Pacific Coast Corvette Club Membership Renewal Form

1. MAIL TO: Pacific Coast Corvette Club
PO Box 14
Coos Bay OR 97420
MEMBERSHIP RENEWAL
Dues are $30 per year per household (couple)
Renewals are due by March 1, 2010 or your name will be omitted from the membership list.
I/We hereby renew my/our membership in the Pacific Coast Corvette Club in the classification indicated
above. I/We agree to abide by the Constitution and Bylaws of the Club and regulations governing its
operation as adopted by the membership.
NAME: ______________________________________________________________Birthday & Month _________________
ADDRESS: ____________________________________________CITY: ________________ ZIPCODE _________________
SPOUSE/OTHER: ___________________________________________________ Birthday & Month ______________________
HOME PHONE: ___________________________FAX: ___________________________CELL: ________________________
BUSINESS PHONE: ____________________________________ (do not list if you don’t want to be called)
EMAIL ADDRESS: _____________________________________________________
Do you want your phone number to be published for others to see? YES __________ NO _____________
CORVETTE INFORMATION
MODEL: _______________________________COLOR: _______________________ YEAR: _________________
SPECIAL FEATURES: __________________________________________________________________________
MODEL: _______________________________COLOR: ________________________YEAR: ________________
SPECIAL FEATURES: _________________________________________________________________________
SIGNATURE OF APPLICANT ____________________________________________________________________
Please return this form and your check to the address above. Thank you.