Primary Name (First, Middle Initial, Last)
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Spouse/Companion Name (First, Middle Initial, Last)
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P.O. Box
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Street
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City State Zip Code
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Phone Number (including area code)
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E-Mail Address
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Corvette Information
Year Color Check one: Coupe Convertible Hardtop
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**2007 GPCC & NCCC Dues are $75.00 per couple**
Please make check payable: Great Plains Corvette Club
Mail to: Great Plains Corvette Club
P.O. Box 366
Imperial, NE 69033
Attention: Julie Ferguson
Primary Signature Date Spouse/Companion Signature Date
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