OTISFIELD TRAILBLAZERS
SNOWMOBILE CLUB
MEMBERSHIP APPLICATION FORM
(CLUB YEAR SEPTEMBER, 2010 - AUGUST, 2011)
FAMILY MEMBERSHIP ____ INDIVIDUAL ___ (check one)
FIRST NAME __________________ LAST NAME ______________
MAILING ADDRESS __________________________________________
CITY/TOWN _________________________________ STATE ______
ZIP CODE ________ TEL #(___) ____________ DOB: ____________
TO SAVE POSTAGE WE'D LIKE
YOUR E MAIL ADDRESS ______________________________________
FAMILY OR INDIVIDUAL MEMBERSHIP IS $22.00. THIS INCLUDES MEMBERSHIP TO THE MAINE SNOWMOBILE ASSOCIATION ( MSA ). MSA MEMBERSHIP INCLUDES INSURANCE FOR PRIMARY APPLICANT.
** ADDITIONAL ACCIDENTAL DEATH & DISMEMBERMENT COVERAGE OF ELIGIBLE
DEPENDENT AVAILABLE FOR $2.00 PER DEPENDENT.
PRIMARY APPLICANT'S BENEFICIARY (for MSA Insurance)
NAME: ________________________________ DOB: _______________
IF OPTING FOR COVERAGE FOR A DEPENDENT:
DEPENDENT'S NAME: _________________________ DOB: ___________
BENEFICIARY: _______________________________
DEPENDENT'S NAME: _________________________ DOB: ___________
BENEFICIARY: _______________________________
DEPENDENT'S NAME: _________________________ DOB: ___________
BENEFICIARY: _______________________________
DEPENDENT'S NAME: _________________________ DOB: ___________
BENEFICIARY: _______________________________
Please make check payable to Otisfield Trailblazers and mail to 55 Bow Street, Otisfield, ME 04270
** An Eligible Dependent is the named member's spouse and any unmarried dependent child who is at least 14 days, but less than 19 years of age and not in active military service. Children include natural, step, foster or adopted children.
