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 __________________________________________________

Additional Dependent Insurance is available for member's spouse and children 18 or under at no cost, but all dependents to be covered must be listed below.

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 and information for 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: