NAME:_________________________________________________________ DATE:______________
ADDRESS:______________________________________________________ NHSA #_____________
CITY/TOWN:______________________ STATE:_____________________ ZIP CODE:__________
HOME PHONE: (_____)_____________________ CELL PHONE: (_____)_____________________
EMAIL ADDRESS :_______________________________________________
DO YOU WANT TO RECEIVE THE NEWSLETTER? YES__________ NO_____________
**NEWSLETTER WILL BE SENT THROUGH EMAIL IF AN ADDRESS IS PROVIDED**
LOCAL ADDRESS:_____________________________________________________
LOCAL TELEPHONE NUMBER:(_________)_________________________
SINGLE MEMBERSHIP (age 18 or older) $20.00 $_______________
(includes membership to New Hampshire Snowmobile Association)
FAMILY MEMBERSHIP (2 adults and children under 18) $25.00 $_______________
(includes membership to New Hampshire Snowmobile Association)
PLEASE LIST FAMILY MEMBERS____________________
____________________________________________________
____________________________________________________
OVER 65 MEMBERSHIP (SEE REQUIREMENTS) $10.00 $______________
(includes membership to New Hampshire Snowmobile Association)
Applicant must be a minimum of 65 years of age.
Must have been a member of the Hardy Country Snowmobile Club for FIVE (5) consecutive years.
DONATIONS: GENERAL CLUB $_______________
GROOMING $_______________
GROOMER $_______________
EASTER SEALS $_______________
TOTAL PAID $_______________
APPLICANT'S SIGNATURE:_______________________________________________________
