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Membership Application Form. - LAKESHORE SPORTS CAR CLUB

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Membership Application Form. - LAKESHORE SPORTS CAR CLUB Powered By Docstoc
					                        Lakeshore Sports Car Club
                           Affiliate – MIDWESTERN COUNCIL OF SPORTS CAR CLUBS
                                          lakeshoresportscarclub.org

                                            2011
                          MEMBER APPLICATION AND INFORMATION FORM

NAME: ______________________________                           SPOUSE'S NAME: ____________                           _____

BIRTHDATE(s) (Month/Day Only) ________________________                                  __

ADDRESS __________________________________________________________________

CITY, STATE, ZIP ____________________________________________________________

PHONE:
(Home) ____________________ (Work) ___________________ (Cell) ________________ __ _

EMAIL* __________________________________________________

TELL US ABOUT YOURSELF:
DO YOU HAVE A RACECAR? __________________                            TYPE \ CLASS      ___           ______________

WHAT ARE YOUR INTERESTS IN RACING?
PLEASE CHECK ALL THAT APPLY:

 RACE STAFF                                                             ROAD RACING
 HIGH/LOW SPEED AUTO X                                                 VINTAGE/HISTORIC
                    SEND APPLICATION AND CHECK PAYABLE TO "LSCC" TO:

                             Stephanie Andersen, LSCC Membership Chair
                                         900 Kingston Ave.
                                          Racine, WI 53402

                        For membership related questions/inquiries, contact Stephanie
                         via phone (cell): (262) 880-9630 (5 pm to 9 pm on weekdays)
                                 or e-mail: lakeshoreccregistrar@gmail.com

Dues:       Member - $45.00
            New                                                          Renewal - $45.00
           Spousal/Family - $5.00 ***                                    MC Club Member - $5.00 ***
                                                                          Dual

If renewal, what year did you first join Lakeshore: _____________

 *E-mail address is required because LSCC monthly Newsletters and other communications are sent via e-mail.
*** Provides liability insurance coverage as a member at LS sponsored events. Meant for those who do not need
 MC racing points, or who do not hold a position as an Officer. MC mailings are also not included. Dual member-
       ship is for those who list another MC club as their club of record, but wish to be on our mailing list.

MEMBERSHIP FORM 2011

Office Use Only: Paid ck# ______________ Card _____   Letter _____ Decals _____ Patches (1L-2S) _____ Updated List ______

				
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