MEMBERSHIP APPLICATION FORM

(please print) 

ð        PBSC Member ($24.00)      

ð        Associate Member ($12.00) Current member of ___________________________Club     

ð        Business Member ($40.00)     

Name: 

Address:

City, State, Zip:

Telephone:

E-mail Address:

Date of Birth:

I would like to help with __ activities, __ trails, __ landowner relations,  __ club rides, __ fundraising, __ just support the club as a member

Beneficiary for Insurance:

Total # of Family Members:

You may purchase additional insurance for $2 per dependent, which is a spouse or a dependent child under 19 years of age.  Please list additional dependent  below (add $2 for each additional dependent):

Name:

Date of Birth:

Relationship to Member:

Beneficiary:

Checks should be made out to:                     Paul Bunyan Snowmobile Club

and mailed to:                                                                             PO Box 2144

                  Bangor, ME  04402-2144