Print out this page and fill out the information and send with it $25.00 or $15.00 for Associate Membership to:
Slippery Sliders Snowmobile Club
P.O. Box 164
Roxbury Me. 04275
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MSA Family Membership Name:______________________________________________________ Mailing Address:______________________________________________ City/Town:___________________________________________________ Zip Code:__________________ Telephone Number:_________________________________________ Date of Birth:_________________________________ E-Mail Address:________________________________________________ Beneficiary for MSA Insurance:_____________________________________ Total Number of People in Family:________________________ |
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Additional Accidental Death and Dismemberment Coverage is free this year for Dependents. Dependents Name:_______________________________________________ Date of Birth:________________________Relationship:_________________ Beneficiary:____________________________________________________ |
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Dependents Name:________________________________________________ Date of Birth:________________________Relationship:________________________ Beneficiary:______________________________________________________ |
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Dependents Name:_______________________________________________ Date of Birth:________________________Relationship:_________________ Beneficiary:_____________________________________________________ |