Maryland Chevelle Club Membership Application Name:______________________________________________ Birthday Month and Day: __________ Spouse/Significant Other: __________________________Birthday Month and Day: __________ Child(ren) Name(s):___________________________________________________________________ Street Address: ______________________________________________________________________ City ____________________________ State _________________ Zip Code ___________________ Home Phone: ____________________________ Today's Date: _______________________________ Occupation: __________________________________________________________________________ Company Name: ________________________________________________________________________ Work Phone: ______________________________ FAX number: _______________________________ If you have E-mail, what is your E-mail address:______________________________________ Other hobbies/interests: _____________________________________________________________ How did you learn about the Maryland Chevelle Club? __________________________________ Tell us about your Chevelle(s)/El Camino(s)[Include photos, if available] Model & Year of your car _____________________________________________________________ Exterior Color: _______________________________ Interior Color: ______________________ Engine & Transmission ________________________________________________________________ Options: _____________________________________________________________________________ How would you describe your car? (check all that apply) ___ original Unrestored ___ original restored ___ mild modified ___ race car ___ modified/custom ___ daily driver ___ show car ___ other ___ in various parts and pieces in a garage (please explain): _______________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ See Reverse Side Do you have more than one Chevelle/El Camino? Model & Year of your car _____________________________________________________________ Exterior Color: _______________________________ Interior Color: ______________________ Engine & Transmission ________________________________________________________________ Options: _____________________________________________________________________________ How would you describe your car? (check all that apply) ___ original Unrestored ___ original restored ___ mild modified ___ race car ___ modified/custom ___ daily driver ___ show car ___ other ___ in various parts and pieces in a garage (please explain):_________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Are you a member of American Chevelle Enthusiasts Society (ACES)? __yes (#______) __no Are you a member of the Late Great Chevrolet Association? __ yes (#__________) ____ no Do you own your own business or have a side business? ____ yes ____ no If so, what is the name of the business? _______________________________________ Nature of the Business? ________________________________________________________ Discount available to MCC Members? ____ yes ____ no If so, How much? _______________________ Would you like to be included on MCC E-Mail distributions? ___ yes ____ no -------------------------------------------------------------------------------------- Please print out the above form and return with Membership Dues. Please make your $25 check (or Money Order) payable to: Maryland Chevelle Club. Mail to: Maryland Chevelle Club c/o Debra Radcliffe-Borsch 2510 Pfefferkorn Rd. West Friendship, MD 21794 JOIN TODAY!! JOIN TODAY!! JOIN TODAY!!