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ACADIA REGION CORVETTE CLUB
Membership Application Make check payable to Acadia Region Corvette Club and send with this form to:
Dan Bossert
36 Salt Pond Road Hancock, ME 04640 Choose Membership Type: ____ Family ($35.00) ____ Single ($17.50) Effective March 1, 2010 Name(1): RETIRED? Y N Name(2): RETIRED? Y N Preferred Nickname (1): Preferred Nickname (2): Address: City/ST/ZIP: Home Phone: Cell Phone(s): Birthday(1) MM/DD: Birthday(2) MM/DD: Anniversary: MM/DD: E-mail: ___________________________________________________________________
CORVETTE INFORMATION (Corvette Ownership not required) Car #1 Year: Car #2 Year: Model: Model: Color: Color: Engine: Engine: License Plate: License Plate: . Add additional Corvettes on back of the form if you wish Please complete this form and return it to a club officer or mail it to the above address. Please indicate the amount you’ve enclosed to cover your 1-year membership fee + a one time $5.00 administrative fee: $_________.
You will receive a package of information about the club and are encouraged to participate in all club activities.
Please note: All club meetings are smoke free and smoking is discouraged at all other functions.
The items in BOLD print on the application will be included in a
Membership List that will go to all club members.
Please circle YES if that’s all right with you or NO if it’s not. YES NO
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