Date: ___________________________
Name: __________________________ Spouse: _________________________
Address: ________________________ Home Phone #: ___________________
City: ___________________________ Cell Phone # _____________________
State: _____________ Zip: _________ Email Address: ___________________
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Corvette(s) you own:
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(Year) (Color) (Coupe or Convertible)
(Stock or Modified)
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(Year) (Color) (Coupe or Convertible)
(Stock or Modified)
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(Year) (Color) (Coupe or Convertible)
(Stock or Modified)
Agency with whom your vehicles are insured: ____________________________________
Applicant’s Signature: __________________________ Sponsored by: ______________
Dues prorated as follows: Join Jan – Mar: $35.00
Apr – Jun: $26.25
Jul – Sep: $17.50
Oct – Dec: $ 8.75
For more information contact:
Judy Williams (270) 753-6088 or email: rjwilliams@newwave.com
Keith or Mary Lou (270)
753-8008 or email: ckbud@email.com
HOLD HARMLESS AGREEMENT
(Must be signed by all members)
Whereas owner voluntarily enters his or her vehicle in THE GLASS PACK, it is agreed as follows: That in consideration THE GLASS PACK, permitting the undersigned owner(s) to participate in this club, the owner(s) agree(s) as follows:
§
That Owner(s) will insure
his/her vehicle against loss, damage and liability and will provide proof of
such insurance being in full force and effective to
THE GLASS PACK.
§
That Owner(s) do/does hereby
agree to indemnify and hold harmless, THE
GLASS PACK, its officers, agents,
employees or assignees for any acts or omissions which may result in the
theft, damage, destruction or injury occurring during or as a consequence of
any event, wherever located and
§
That Owner(s) in attending any
event do/does so voluntarily and agrees and assumes the risk of any and all
damage to his/her vehicle or of injury to himself/herself or other persons
and holds THE GLASS PACK harmless thereof.
Registered Vehicle 1:
______________________________________________
Insured with:
_____________________________________________________
Registered Vehicle 2
______________________________________________
Insured with:
_____________________________________________________
Registered Vehicle 3:
______________________________________________
Insured with:
_____________________________________________________
Registered Vehicle 4:
______________________________________________
Insured with:
_____________________________________________________
Registered Vehicle 5:
______________________________________________
Insured with:
_____________________________________________________
Owner(s) Signature(s):
_____________________________________________
_____________________________________________
Received by:
__________________________
Date: _________________