Name____________________________________________   Spouse_______________________________
Address_________________________________________________________________________________
City_______________________________________________  State____________  Zip________________
Home Phone________________________________    Cell Phone__________________________________
Spouse's Cell_______________________________    E-mail______________________________________
Corvette(s)
Year_________  Color______________________  Style (Coupe, Conv., Z06, etc.)___________________
Year_________  Color______________________  Style (Coupe, Conv., Z06, etc.)___________________
Year_________  Color______________________  Style (Coupe, Conv., Z06, etc.)___________________
Other "Stimulating" Automobiles (Ferrari, Mustang, Cobra, Camaro, Challenger, etc.)
Year_________  Color______________________   Style (Coupe, Conv., etc.)______________________
Year_________  Color______________________   Style (Coupe, Conv., etc.)______________________

The following supersedes all previous versions of the MHVCA Membership Form and is applicable to all MHVCA members.


By my signature I authorize the MHVCA to register me as a member of the Mid-Hudson Valley Corvette Association, Inc.  I understand my membership is contingent upon maintaining a valid driver's license and by my signature I agree I shall abide by the MHVCA By-laws.  I further agree that I shall maintain current insurance for any and all vehicles participating in any and all MHVCA activities.  I hereby release MHVCA, their members and officials, all sponsors, their employees, official agents and associates, from any and all liabilities, indemnify and hold them harmless for any individual acts of negligence and or recklessness and claims or damages resulting thereof.


By my signature I hereby state that within the last 5 years I have not been convicted or pled guilty to any serious driving infraction involving criminal conduct such as vehicular assault, uninsured operation of a motor vehicle, reckless driving, DWI, or DWAI nor have I had my drivers license or automobile insurance denied, revoked, restricted or voluntarily surrendered on the basis of criminal charges.


By my signature I hereby state that the above information is true and accurate, and if there are any changes in the above information, I will notify MHVCA in writing, of such change and provide documentation if necessary.

Member's Signature__________________________________________    Date__________________


Spouse or Significant Other's Signature_____________________________________________________                    

Make checks payable to MHVCA for $50 Annual Dues (October 1 to September 30)
THE SUBMISSION OF AN APPLICATION IS NOT A GUARANTEE OF MEMBERSHIP.    

MHVCA_Emblem.jpg

APPLICATION FOR MEMBERSHIP FORM


Mail To: Mid Hudson Valley Corvette Association                   

c/o David Goldfarb, 152 Duncan Avenue, Cornwall-On-Hudson, NY 12520