Kokadjo Roach Riders Snowmobile Club Application

c/o P.O. Box 253

Hallowell,  ME. 04347

Date:___________________________

Name:________________________________________________________________

Mailing Address:______________________________________________________

City:___________________________________   State:_____   Zip:______________

Date Of Birth:_______________________ Telephone: ______________________

Email Address:________________________________________________________

Beneficiary:___________________________________________________________

Additional Dependents @ $2.00 each, under 18yrs old

Name:_______________________________________________________________

Relationship: ____________________________ Date Of Birth: ____________

Beneficiary:_________________________________________________________

Name:_______________________________________________________________

Relationship: ____________________________ Date Of Birth: ____________

Beneficiary:_________________________________________________________

Dues: Single - $20.00 plus any additional dependents @ $2.00 each

          Family- $30.00 plus any additional dependents @ $2.00 each

All fees on this page are a yearly membership rate