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Kokadjo Roach Riders Snowmobile Club
Membership Application

Kokadjo Roach Riders Snowmobile Club
c/o Heidi Mansir
638 East Pittston Road
Pittston, ME 04345
johndiskes@kokadjoroachriders.org

Date: __________________________

Member Information

Name: _________________________________________________________

(first)                                                    (last)

Mailing Address: __________________________________________________

City: _____________________________ State: _____ Zip: ________________

Date of Birth: _______________________ Telephone: ___________________

Email Address: ___________________________________________________

Beneficiary: _____________________________________________________


Additional Family Dependants (Spouse & Children under 18 yrs old - $2.00 each)

Name: _________________________________________________________

Relationship: _______________________ Date of Birth: __________________

Beneficiary: _____________________________________________________

 

Name: _________________________________________________________

Relationship: _______________________ Date of Birth: __________________

Beneficiary: _____________________________________________________

 

Name: _________________________________________________________

Relationship: _______________________ Date of Birth: __________________

Beneficiary: _____________________________________________________

 

Name: _________________________________________________________

Relationship: _______________________ Date of Birth: __________________

Beneficiary: _____________________________________________________


Dues:

  • Single - $30.00 (plus any additional dependents at $2.00 each)
  • Business - $100.00 (dependents do not apply)

All fees on this page are a yearly membership rate.

Please make check payable to Kokadjo Roach Riders Snowmobile Club.

If mailing please send to:

Kokadjo Roach Riders Snowmobile Club
c/o Heidi Mansir
638 East Pittston Road
Pittston, ME 04345