Memberships

Become a member! Support the Sport!!

2012-2013 Club Membership Application

ATTENTION!!!!

THE (1) PERSON LISTED AS THE THE PRIMARY MSA MEMBER IS COVERED BY A $2500 DEATH/DISMEMBERMENT POLICY.

ELIGIBLE DEPENDENTS ARE ALSO COVERED AT NO ADDITIONAL CHARGE BUT MUST BE LISTED ON YOUR MEMBERSHIP APPLICATION BELOW!!

If you are paying by check please remit payment to: PLSC @ PO Box 149, Portage Lake, ME 04768 ATTN: Membership Chair

If you are paying via Paypal you will be sent an invoice in the next 24 - 48 hours (a $2.00 transaction fee will be applied)

*indicates required fields

*Member/Business Name:

*Address:

*City, State, ZIP:

*Email Address:

*Phone Number:

*Date of Birth (DOB):

*Member's MSA AD & D Ins Beneficiary:

*Membership Dues:

MSA/Club Business Member - $50
MSA/Club Family Member - $30
Club ONLY Business Member - $25
Club ONLY Family Member - $15

Name / DOB / Beneficiary/Relationship:

Name / DOB / Benificiary/Relationship:

Name / DOB / Benficiary/Relationship:

Name / DOB / Benficiary/Relationship:

*DONATIONS:

SNOW!!!!!:

YES!!!

*TOTAL DUE:

*Payment Method:

After filling the details click on the SUMBIT button.

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