First Name: Last Name:
Street Address:
City, State/Province, Postal Code:
Country:

E-mail address: Phone:

Model Year of Your Corvette(s):

Payment Method:

Payment information must be provided before we can process your order. Annual membership dues are $39.

Choose One: MasterCard VISA

Card Number: Expiration Date:

Free Insurance:

Your FREE Accidental Death and Dismemberment insurance coverage becomes effective the first month following acceptance and receipt of payment. If you do not designate a beneficiary, your estate will become the beneficiary. Please complete the following information. You can change this designation at any time by notifying us in writing. Note: The full name of the beneficiary must be supplied. If the beneficiary is a minor, you must supply the date of birth for that beneficiary.

Primary Beneficiary: Relationship: DOB:

Contingent Beneficiary: Relationship: DOB:

Special Instructions: