MASON DIXON CHAPTER, NCRS
Chapter Membership Chairperson/Vice President
9030 Fieldchat Rd.
Baltimore, MD 21236
Phone: (410)-256-1570/Fax: (410)-877-3870/E-Mail: pgongloff@aol.com
Membership Application
(National NCRS membership is required for chapter membership)
Name: _________________________________________________________________________
Address: ________________________________________________________________________
City: ___________________________________________________________________________
Phone Numbers: Home( ) ___________________ Work ( ) _____________________
Fax ( ) ___________________ E-Mail Address __________________
NCRS Membership Number: _______________________(required for Chapter Membership)
Corvettes Owned:
Year Model Engine/Trans Options
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Dues: (Make check payable to MASON DIXON CHAPTER of NCRS)
Check One
$35.00 for One Year ______ $150.00 for Five Years ______ $300.00 for Lifetime______
Print off and fill in Application
Mail Check and Application to:
Fred & Dawn Prediger, Membership
9030 Fieldchat Rd.
Baltimore, MD 21236