LEBANON TRAIL RIDERS P.O. BOX 33 LEBANON, ME 04027 Family Membership Dues (   )   $25.00     Single Membership   (   ) $20.00 Fill out and make checks to "Lebanon Trail Riders" you can mail to the above address or bring to meeting which is the First and Third Wednesday of each month, 7 PM, Check web site for dates and location, www.lebanontrailriders.com   This is for the 2007-2009 Snowmobile Year. Name: __________________________________________ DOB: ______________ Mailing Address: ___________________________________________ City/Town: ___________________ State: _______________________ Zip Code: _________________ Phone:   (______ ) _______________________   Present Date: ______________ Email Address: _____________________________ If you want to be contacted about meetings/trail work. Beneficiary of MSA Insurance____________________ Relationship________ Additional insurance for Accidental Death or Dismemberment Coverage for Eligible Dependent(s) is available at an added cost of $2.00 for each. Only immediate family members are considered dependents, i.e. spouse or unmarried children under age 19. Dependent name_____________________ DOB________ Relationship Child/Spouse: ________________________ Beneficiary: __________________________ Thank You for becoming a Lebanon Snowmobile Club Member