MEMBERSHIP APPLICATION / RENEWAL
Date: _______________ New Member ________ Renewal ________
Pease check one
Name: ________________________________________________ Birthday (mm/dd) _____
Spouse/Significant Other ___________________________________ Birthday (mm/dd) _____
Mailing Address: ____________________________________________________________
City: _____________________________________________ State ______ Zip _________
Home Ph ( ) ______________ Cell Ph #1 ( ) ____________ Cell Ph #2 ( ) _____________
Email address #1: ___________________________________________________________
Email address #2: ___________________________________________________________
Corvette Info:
Year Color Special Information
________ __________________________ _________________________________
________ __________________________ _________________________________
________ __________________________ _________________________________
________ __________________________ _________________________________
Club dues are $25.00 and include member and spouse/significant other.
Make check payable to LTCC and mail along with this form to:
Barbara Coe
10150 N. Empey Dr
Stagecoach, NV 89429
