Membership Application Information Request

Bath Sno-Flakes Snowmobile Association

6993 Cty Rte 15

Bath NY  14810

PLEASE PRINT

First Name   ______________________________________________

Last Name   ______________________________________________

Street Address/PO Box  _____________________________________

Town/Village_________________State    ___________ Zip Code___________

Family Membership Information ($5.00 for each additional Family Member)

First Name ___________________ Last Name_________________________ 

First Name ___________________ Last Name_________________________ 

First Name ___________________ Last Name_________________________  

First Name ___________________ Last Name_________________________   

First Name ___________________ Last Name_________________________   

Children under 18 that intend to register a sled ______________________________________________________________________

Phone #_____________________________

Email   _____________________________{Required for login to NYSSA Membership Site and e-mail of  DMV Voucher, NYSSA News Letter, and other information.}

   (  ) Your membership types and prices {individual $25.00 Each Additional member $5.00}

   (  ) NYSSA Trail Defender membership upgrade additional $20.00

Have you already paid NYSSA Dues this season via another club?  __________

If so, which Club  __________________________________________________

Please enter the number of snowmobiles you intend to register __________

[  ]  Twenty five cents of your $5 NYSSA dues will be used for the NYS Snowmobile PAC (Political Action Committee) who is our voice in Albany. If you do not wish to contribute to the NYS Snowmobile PAC, please check this box. Please note, your NYSSA dues remain $5.00.

_____________________________________________________________________

For Club use only

Blank Voucher ID issues (ex 07-140-B183):  ______________________________

Snowmobile Trail Land Owner  (    )