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.