NCCC Member Application

This application is for individuals wanting to join NCCC. Please print neatly or type all information
Club Affiliation: _______________________________________________________________________
Primary Name: _____________________________________ Male ______ Female ________
Spouse / Companion: __________________________________ Male _______ Female _______
Youth Name: ___________________________________ Male ______ Female _____ Date of Birth__________
Address: _____________________________________________________________
City: _____________________ State: ______ Zip ______________
Phone Number: ____________________________ E-Mail________________________________________

Membership Type
______ Primary NCCC Membership $35.00 (New or Late Renew)
______ Spouse/ Companion Membership $10.00
______ Youth Membership $10.00
______ Lifetime Membership $335.00 (One time charge)
______ Primary Member at Large $35.00 (Not in an NCCC corvette club at this time)
______ Spouse/Companion Member at Large $10.00 (Not in a NCCC corvette club at this time)
______ Enthusiast (New) $35.00
______ Active Member Transfer from NCCC Club #
______ Change of Name or Address Enter changed information at top of page
______ Previous NCCC Member? If so what year? ______________
If Previous NCCC Member what was your old NCCC number? ___________________

Corvette Information
Year __________ Coup, Convertible, or Fixed Roof __________________________
Application Signature(s) _________________________________ Date ______________
_________________________________ Date ______________
This certifies that I am at least 16 years of age.
Annual dues for membership in NCCC for the year are $35.00. $10.00 of this amount is for one year-year subscription to Blue Bars.

These Dues are for the year of ______________

RMD Initials ____________ Date: __________

Forms Revised 4/29/2014