* * * THIS FORM IS IN TEST MODE ONLY AND ISN'T READY FOR FORM SUBMISSIONS YET. * * * SCRVCCA Membership Application Club Membership Information: REGION: All members receive a monthly region newsletter and information on upcoming events and tours. NATIONAL: All new members will receive a club badge, decal, membership card and the national magazine, Generator & Distributor. Members are entitled to free classified advertising in the club magazine and participation in Vintage Chevrolet Club activities. Members are entitled to free classified advertising, access to member-only website features, and participation in all VCCA activities. Chevrolet ownership is not a requirement for membership. Dues are non-refundable. The purpose of the VCCA is to promote interest in the preservation and restoration of vintage Chevrolets. Required Member Data: Primary Member's First Name* (required) Primary Member's Last Name* (required) Home Street Address* (Required) City* (Required) State* (Required) Zip Code* (Required) [ Format - XXXXX-XXXX ] Your Email* (required) Are you a member of the National Vintage Chevrolet Club?* (Required) YesNo Additional Member's Personal Data: If you are a National VCCA Member, indicate your National VCCA Member Number NOTE: FOR INSURANCE PURPOSES ALL REGION MEMBERS MUST JOIN NATIONAL IN ORDER TO JOIN THE REGION. If you send the Region, your National dues, we will send them on to National. Primary Member's Birthdate [ Format - mm/dd/yyyy ] Family Member's First Name Family Member's Last Name Family Member's Relationship to Primary Member SpousePartnerOther Family Member's Birthdate [ Format - mm/dd/yyyy ] Anniversary [ Format - mm/dd/yyyy ] Family Member's Email Your Home Phone [ Format - (XXX) XXX-XXXX) ] Primary Member's Cell Phone [ Format - (XXX) XXX-XXXX) ] Family Member's Cell Phone [ Format - (XXX) XXX-XXXX) ] Member's Vehicle Data: Vehicle 1: Vehicle 1 Year Vehicle 1 Model Vehicle 1 Body Style Vehicle 1 Engine Cylinders ---4-Cylinder6-Cylinder8-Cylinder Vehicle 1 Condition ---ExcellentGoodPoor Vehicle 2: Vehicle 2 Year Vehicle 2 Model Vehicle 2 Body Style Vehicle 2 Engine Cylinders ---4-Cylinder6-Cylinder8-Cylinder Vehicle 2 Condition ---ExcellentGoodPoor Vehicle 3: Vehicle 3 Year Vehicle 3 Model Vehicle 3 Body Style Vehicle 3 Engine Cylinders ---4-Cylinder6-Cylinder8-Cylinder Vehicle 3 Condition ---ExcellentGoodPoor Vehicle 4: Vehicle 4 Year Vehicle 4 Model Vehicle 4 Body Style Vehicle 4 Engine Cylinders ---4-Cylinder6-Cylinder8-Cylinder Vehicle 4 Condition ---ExcellentGoodPoor Referral Information: If you were referred to join the club by a VCCA Member, please provide the member's name and VCCA No. (if known). [ Format - First Name, Last Name / VCCA # ] NOTE: All data requests marked with an * are required fields. Upon form submission, you can checkout and pay for your membership dues via PayPal. After your payment is processed by PayPal you will be auto-redirected back to SCRVCCA.org. An auto-generated e-mail will be sent to your e-mail to provide you with a confirmation of the information you provided to us via this form.