Sebago Branch Duckers

MEMBERSHIP APPLICATION

Name:

Address:

City: State: Zip:

Telephone: Birthdate:

Spouce:

Birthdate:

Children: Birthdate:

Children: Birthdate:

Children: Birthdate:

Children: Birthdate:

ANNUAL DUES:
$20.00 per family
$15.00 per single

Includes $10.00 for M.S.A. Dues and insurance for ONE MEMBER.
Insurance benefits include $2000.00 for accidental death. Add $2.00 for each
ADDITIONAL member insurance.

BENEFICARY FOR MSA INSURANCE:

Email:

Make check payable to:
Sebago Branchduckers
P.O. Box 156
Sebago, ME, 04029

Note: Membership in the Maine Snowmobile Association (MSA) is required.