Check membership type:  Family ___   Business ___  Associate___

Name ______________________________________________ Date ___________________

Address ____________________________________________ Zip ____________________

City/Town __________________________________________ State ___________________

Tel. __________________ Date of Birth ________________

Total Number of Members in Family ___________

E-mail Address _____________________________________

Beneficiary for MSA Insurance __________________________________________________

Optional Additional Dependent Insurance is available for member's spouse and children 18 or under at a cost of $2 per dependent.

Additional Dependent Insurance for

Name ____________________________________ Date of Birth ____________

Relationship _________________ Beneficiary _________________________

Additional Dependent Insurance for

Name ____________________________________ Date of Birth ____________

Relationship _________________ Beneficiary _________________________

(If more than two dependents are to be insured, list names of additional dependents on a separate sheet of paper.)

A Family Membership is $25.00. If you are already a member of another club, you can join the Polar Bears as an associate member for $15.  A Business Membership is $35.00.  Please make check payable to Rumford Polar Bears Snowmobile Club and send check with completed application to: