First Name
Last Name
Current E-mail
Phone	(no dashes please)
Address
City
State or Province
ZIP
Country
Your Age
Yr of your Vette	separate multiple yrs by commas
Name as you want it to appear on your membership card and Plaque
Your Bio, Brief Corvette History or interesting facts:
Why do you think you should be considered for Lifetime Membership?
What size Limited Edition CCA Polo would you like to receive?
Small Medium Large XLarge XXLarge
If your application for lifetime membership is declined you will receive a full refund of the $500.00 lifetime membership fee.
Credit Card Type:	VISA MasterCard
Credit Card Number	Do not use hyphens, dashes or spaces, please
Expiration Date (month and Year)	January February March April May June July August September October November December 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Name on Card
Your credit card information will not be recorded and is only used to process this membership application over a secured network. You will receive an email receipt of this transaction so be sure your email address is entered correctly above.
$50.00 is added for Foreign or Canadian Memberships.