Prospective Member Form

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Primary Member Information

*First Name:		*Last Name:
Email Address:

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Spouse /Significant Other Information

First Name:		Last Name:
Email Address:

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Address and Phone Number Information

*Street Address:
*City:		*State:		*Zip Code:
Phone (ex: (719) 555-1212):

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Corvette Information
*Car Year, Color, Body Style:

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Club Information:
Club Member's name I know:
Interests:

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