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1114 N. Everett St., Glendale CA 91207

Initial Application: ____ Renewal Application: ____ (Due by 1st Sat. in Feb.) Date Joined Club ____
(Please complete application in its entirety, even if a Renewal.                            Do not indicate “same as before”. Please print)
Membership Information:
Name: _____________________________ Birth date: ___________ Occupation: __________________
Spouse: ____________________________ Birth date: ___________ Occupation: __________________
Add’l Licensed Family for Membership Name: ________________________ Birth date: ___________
   (Of driving age and living with member) Name: ________________________ Birth date: ___________
Mailing Address: _______________________________City: _______________ Zip: _______________
          Home Phone: ________________________ Business or Cell Phone: ____________________
          Email Address(s) (if you want listed on the club roster): ____________________________
Oldest Corvette: Year ______ Color _______ Lic No ________ Yr Purch’d ____ Coup or Conv ____
       Original or Modified ____ Engine Size ____ Horsepower _____ Transmission _______

Other Corvettes:                 (1) Year _______ Color _______                           Coup or Conv ________
                                 (2) Year _______ Color _______                           Coup or Conv ________

                       (Please use back of Application for following information)
  Other Clubs: Name of other Corvette Clubs to which you belong.
Event Interests: Please list events or activities that would be of interest to you.
Membership Dues: Membership Dues are for a period of one year. (Feb. to Jan)
              Initial Membership Fee: (for all New Members, one-time fee):
               ______ One Member ($15.00)
               ______ Two or more Members ($17.00)
              Initial / Renewal Fees: (for all new and renewal Members)
              ______ Member ($50.00) Includes two household members
              ______ Add’l Family Members ($10.00 ea)
                                            Please make check payable to: V.C.S.C., Inc.
                                  Send to: Loretta Loddo, 1114 N. Everett St., Glendale, CA 91207
I hereby agree, as a condition of my membership in VINTAGE CORVETTES OF SOUTHERN CALIFORNIA, INC., that I am joining this club for my own pleasure and will be
fully responsible for my actions at all times. I fully understand that I am responsible for having in effect a current insurance policy, as required by State Law, on my vehicle(s) when
used for any V.C.S.C. functions, events or activities, that will cover any accidents or incidents that I may be involved in during any club-supported events. I release VINTAGE
CORVETTES OF SOUTHERN CALIFORNIA, INC., its assignees, officers, heirs, and all others, connected with the club, heretofore, from any liability, whatsoever. I also agree as
a condition of my membership in VINTAGE CORVETTES OF SOUTHERN CALIFORNIA, INC., that I will not use the club logo or any club item with the V.C.S.C. logo or
promotional purposes of any kind.

_______________________________________                     ________________________________                     _____________________________________
Applicant                           Date                     Spouse                       Date                    Sponsoring Member                 Date
For V.C.S.C. use:
Date Rec’d____________         _______________________ ________                                        _______________________ _________
 Fee Paid: ____________ Membership ____ President’s Signature                                          Date Secretary’s Signature                               Date