Application for Membership

Date:_____________________________________________________________________________

Applicant's Name:________________________________________________________________

Spouse's Name:___________________________________________________________________

Street Address:____________________________________________________________________

City:_______________________________ State:_______________ Zip:______________________

Home Telephone: (_____)______________ Work Telephone: (____)________________________

Cell Phone (____)_______________ E-Mail:_______________@____________________________

Corvette Year:_________ Style:_____________________ License:_________________________

Corvette Year:_________ Style:_____________________ License:_________________________

Corvette Year:_________ Style:_____________________ License:_________________________

Applicants Signature:_____________________________________________________

Annual Dues:  $35.00

Mail completed application along with check and hold harmless agreement to:

Attn: Membership

Four Rivers Corvette Club

245 Old Farm Road

Paducah  KY  42001

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