Adirondack Chapter
NCRS

Application Form


Name: ________________________________________________
Address: ________________________________________________
________________________________________________
________________________________________________
Phone# ______________
E- mail: ______________
NCRS#______________   Date: ____________

Corvette Owned : Year_______ Coupe / Roadster Color ___________
Note: You do not have to own a Corvette to join



YOU MUST BE A CURRENT NCRS NATIONAL MEMBER TO JOIN
To Join offline by mail, fax or phone:
Contact Gary Mortimer, 6291 Day Road Cincinnati, OH
Phone (513)385-8526 Fax (513)385-8554 here

DUES WILL BE $30.00 PER YEAR
Send a check with Application to:

John Dergosits
863 Turnbull Road
Delanson, New York 12053

Phone: (518) 895-8402 or dergosits1@gmail.com

Make check payable to Adirondack Chapter NCRS Treasurer

For more information on the internet :
http://www.adirondackncrs.com

ADIRONDACK CHAPTER - CHAIRMAN
Lief Larsen
217 First Street
Scotia, New York 12302
llarsen@mmcmillwork.com
(518) 465-4109