APPLICATION FOR MEMBERSHIP FORM

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=80 BGCOLOR="#000000" TEXT="#F7F7FF" bgproperties="fixed" background="03c00500dvldtc.gif"> <div> <FONT SIZE="5" COLOR="#FFCC66" FACE="Arial" ><B>Mid-Hudson Valley Corvette Association</B></FONT><B>     |     </B><A HREF="index.htm" TARGET="_top" TITLE="MidHudson Valley Corvette Association"><U><B>home</B></U></A></div> <div> <B>APPLICATION FOR MEMBERSHIP FORM</B></div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#000000" TEXT="#F7F7FF" background="03dd2c00dvldtc.gif"> <div> <A HREF="id20.htm" TARGET="_top" TITLE="Contact Us"><U>CLICK HERE TO RETURN </U></A></div> <div> <A HREF="id20.htm" TARGET="_top" TITLE="Contact Us"><U>TO </U></A><FONT SIZE="2" COLOR="#FFFF33" FACE="Arial" ><A HREF="id20.htm" TARGET="_top" TITLE="Contact Us"><U><B>CONTACT US</B></U></A></FONT><A HREF="id20.htm" TARGET="_top" TITLE="Contact Us"><U> PAGE</U></A></div> <div> <A HREF="id20.htm" TARGET="_top" TITLE="Contact Us"><U><IMG SRC="072422b0.jpg" border=0 width="66" height="43" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></U></A></div> <bR> <bR> <bR> <div> <A HREF="index.htm" TARGET="_top" TITLE="MidHudson Valley Corvette Association"><U>CLICK on FLAGS to</U></A></div> <div> <A HREF="index.htm" TARGET="_top" TITLE="MidHudson Valley Corvette Association"><U>RETURN to HOME PAGE<IMG SRC="07183360.jpg" border=0 width="131" height="54" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></U></A></div> </td> <td valign="top" height=400 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> APPLICATION FOR MEMBERSHIP FORM</div> <div> <B> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="3" WIDTH="589" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="LEFT" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER COLSPAN=6 HEIGHT= 26 WIDTH="581"><div> <B>Mid Hudson Valley Corvette Association</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=6 HEIGHT= 716 WIDTH="581"><div> <B>c/o David Goldfarb, 152 Duncan Avenue, Cornwall-On-Hudson, NY 12520</B></div> <bR> <div> <B>Name_____________________________________   Spouse___________________________</B></div> <div> <B>Address______________________________________________________________________</B></div> <div> <B>City______________________________________  State______________  Zip_____________</B></div> <div> <B>Home Phone___________________________    Cell Phone___________________________ </B></div> <div> <B>Spouse's Cell_________________________    E-mail_________________________________</B></div> <div> <B>Corvette(s)</B></div> <div> <B>Year_________  Color_______________  Style (Coupe, Conv., Z06, etc.)________________</B></div> <div> <B>Year_________  Color_______________  Style (Coupe, Conv., Z06, etc.)________________</B></div> <div> <B>Year_________  Color_______________  Style (Coupe, Conv., Z06, etc.)________________</B></div> <bR> <div> <B>Other "Stimulating" Automobiles (Farrari, Mustang, Cobra, Camaro, Challenger, etc.)</B></div> <div> <B>Year_________  Color_______________   Style (Coupe, Conv., etc.)___________________</B></div> <div> <B>Year_________  Color_______________   Style (Coupe, Conv., etc.)___________________</B></div> <div> <B>The following supersedes all previous versions of the MHVCA Membership Form and is applicable to all MHVCA members. </B></div> <div> By my signature I authorize the MHVCA to register me as a member of the Mid-Hudson Valley Corvette Association, Inc.  I understand my membership is contingent upon maintaining a valid driver's license and by my signature I agree I shall abide by the MHVCA By-laws.  I further agree that I shall maintain current insurance for any and all vehicles participating in any and all MHVCA activities.  I hereby release MHVCA, their members and officials, all sponsors, their employees, official agents and associates, from any and all liabilities, indemnify and hold them harmless for any individual acts of negligence and or recklessness and claims or damages resulting thereof.</div> <div> By my signature I hereby state that within the last 5 years I have not been convicted or pled guilty to any serious driving infraction involving criminal conduct such as vehicular assault, uninsured operation of a motor vehicle, reckless driving, DWI, or DWAI nor have I had my drivers license or automobile insurance denied, revoked, restricted or voluntarily surrendered on the basis of criminal charges. </div> <div> By my signature I hereby state that the above information is true and accurate, and if there are any changes in the above information, I will notify MHVCA in writing, of such change and provide documentation if necessary.</div> <div> Member's Signature____________________________________    Date_______________</div> <div> Spouse or Significant Other's Signature_________________________________________</div> </tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=6 HEIGHT= 36 ><NOBR><div> Make checks payable to MHVCA for <B>$55</B> Annual Dues (October 1 to September 30)</div> <div> THE SUBMISSION OF AN APPLICATION IS NOT A GUARANTEE OF MEMBERSHIP.</div> </NOBR></tD> </tR> </TABLE></B></div> <bR> </td> </tr></table></body>