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

           ________________________________________________________________________

           ________________________________________________________________________

           ________________________________________________________________________

           ________________________________________________________________________

   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