2011-2012 MEMBERSHIP APPLICATION

SMOKI HAULERS SNOWMOBILE CLUB
PO Box 331, Oakfield, ME  04763-0331
Tel. (207) 757-8478
Meetings are the 2nd Monday of the month @ 7:00 PM

Membership dues include $2,500 insurance for head of household

NAME ____________________________________________________________________
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MAILING ADDRESS __________________________________________________________
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CITY, STATE, ZIP ___________________________________________________________
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TELEPHONE (         ) ____________________ DATE OF BIRTH _______________________
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E-MAIL ADDRESS ____________________________________________________________
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BENEFICIARY _______________________________________________________________
(you must name a beneficiary for the insurance)
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COMPLETE THE FOLLOWING FOR EACH DEPENDENT YOU WISH TO INSURE:

       NAME              RELATIONSHIP             DATE OF BIRTH              BENEFICIARY

1 ___________________________________________________________________________

4 ___________________________________________________________________________

5 ___________________________________________________________________________

What activities would you be interested in?
______ 1. Bridge Upkeep
______ 2. Annual chicken BBQ
______ 3. Poker Runs
______ 4. Kids Day
______ 5. Winter grooming (learn Bombi)
______ 6. Writing an article for the newsletter
______ 7. Landowners appreciation supper
______ 8. Building & grounds upkeep
______ 9. Fundraisers
_____ 10. Public Suppers
_____ 11. Hunter's Breakfast
_____ 12. Christmas Party
_____ 13. Organizing Trail Rides
_____ 14. Trail Work
_____ 15. Brushing
_____ 16. Signages
_____ 17. Secure Use Permits
_____ 18. Help where needed

Membership dues are due in September of each year

NEW_______RENEWAL_______ASSOCIATE_______

Primary Membership including insurance coverage is $30.00
(There is no longer a fee for dependent coverage)

Check#_______Cash________Date Paid_________

I understand that by signing this form, my membership can be discontinued at any time if the Club or its Officers have reason to believe that I or a member of my family operates a snowmobile irresponsibly so that it endangers the Landowner/Club relationship, or it is believed that the operator could cause harm to another individual. My membership fee is nonrefundable and it is to be used to support the club as a whole. I also agree to hold harmless the Smoki-Haulers Snowmobile Club from any liabilities resulting from my involvement with the club.

Applicants signature_____________________Date_______