Northwest Classic Chevy Club 2012
Membership Application

Tell us about yourself!
Full Name
City State Zip
Phone (cell) Phone (home)

What classic Chevy do you drive (or are working on)?
Year Model Color

What work have you done to your car? Stock or modified?


Engine & drivetrain information


If you have photos or want them published on the roster please send them to

Club dues are $25.00 per year (Jan 1 - Dec 31) / Prorated (July to Dec) $12.50

Return this completed form along with your payment to:

c/o Mark Wadzinski
13188 SE Newport Way M-201
Bellevue, WA 98006


Signature Date