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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:
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
Your Hosts:
Fred and Marie Candeloro
Kokadjo Cabins
3424 Lily Bay Road
Kokadjo, ME 04441
(207) 695-3993
marie@kokadjo.com