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:
Mark Hipp
P.O. Box 335
Northville, New York 12134
Make check payable to Adirondack Chapter NCRS Treasurer
For more information on the internet :
http://www.adirondackncrs.com
ADIRONDACK CHAPTER - CHAIRMAN
John Dergosits
863 Turnbull Road
Delanson, New York 12053
jdergosits@empireone.net
(518) 895-8402