Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Spouse Name

First Name

Last Name

Spouse Phone

(###)

###

####

Photography Waiver *

Participation in Corvette Club of Vermont events generally involves many photos of the fun had by all. I understand these photos will be published to our website and social media sites and consent to allowing the club to do so.

Yes

No

Primary Name *

First Name

Last Name

Primary Phone *

(###)

###

####

S/C Name

First Name

Last Name

S/C Phone

(###)

###

####

Youth Name

First Name

Last Name

Youth Phone

(###)

###

####

Mailing Information *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Levels of Membership

Primary NCCC Member- $35 (New or Late Renew)

Spouse/Companion -$10

Youth - $10 (Youth ages 16-21 under the membership of the primary member)

Membership Information Change

Name

Address

Car

Body Style

Coupe

Convertible

Fixed Roof

Z06

ZR1

Applicants Certification

By signing below, I certify that all of the information above is accurate

By signing below, I understand I am signing the NCCC Application Form

By signing below, I certify that I am at least 16 years of age.