Address:__________________________
City:________________________
State:_________________
Zip:________________
Phone: (207)______-_________
E-Mail Address:_________________________________________
Birthdate:______________________
Benificary for MSA Ins.:________________________
Relationship:______________________
Additional Dependants (if applicable):___________________________________________________
Includes $2,000 Life Insurance From The Maine Snowmobile Association
Additional dependants Insurance available for $2.00 Per Dependant
(List Names and Birthdates on above form in appropriate place)
Business Memberships Available for $40.00
Please Make Checks Payable To: