Name ________________________________ Spouse _____________________

Address ____________________________________________

City _______________________________________________

State ________ ZIP _________________

Telephone (______)________ - ____________

* NCRS Membership No. (Required)_____________

E-mail Address:_________________________________________________

* Found on Driveline or Restorer Labelor you can get it from Gary Mortimer, NCRS Membership,
when you call (513) 385-8526 to join the National Corvette Restorers Society.
You must be a member of the NCRS to join the Southern California Chapter.

Dues: $28.00 per year,  Make check or money order  payable to:  SCC/NCRS

Print this application and mail to: Darold Shirwo, Membership Chairman  8484 Wilshire Blvd. #605  Beverly Hills CA 90211  310.287.2000

Corvette’s Owned:
Year __________ Model _____________  Year __________ Model _____________
Year __________ Model _____________  Year __________ Model _____________
Year __________ Model _____________  Year __________ Model _____________

(The following information is needed for Chapter of the Year Competition, please complete.)

Judges/Tabulators Names, Level: ___________________________

Awards: (Duntov, Bowtie, Flight, etc.)
Corvette, yr _________________ Award,yr ________________
Corvette, yr _________________ Award,yr ________________
Corvette, yr _________________ Award,yr ________________
Corvette, yr _________________ Award,yr ________________

Member of the National Corvette Museum? Yes[ ]
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© Southern California Chapter, National Corvette Restorers Society, Inc. 2007