Membership Form – Black Earth/Mazomanie

(Membership year: 2016- 2017)

Primary Member Name: ______

Spouse Name: ______

Child/Age: ______Child/Age: ______

Street Address: ______

City/State/Zip: ______

Telephone: Home: ______Cell: ______

E-Mail Address: ______

I prefer to receive email updates, newsletters, etc., via e-mail instead of regular mail.

Please check club activities you are willing to help with:

Pork Roast fundraiser / Help w/grooming trails / Mark trails/take out / Other fundraisers

Active Family or Single Membership $25: Anyone over the age of 18 must pay individual dues of their own, (they are not included in a family membership).

Secondary Membership $15: If you already have a primary membership with another club, but would like to join County Line Sno Busters, please write the name of your primary club below. This is only $15 because we do not send $10 to the AWSC that your primary membership already covered.

Your current AWSC/club membership will include a monthly subscription to the Wisconsin Snowmobile News Magazine (Sept-March) and a $3,000 Accidental Death & Dismemberment Benefit (American Income Life) policy for the primary member (listed above) and his/her spouse. There is also a benefit of $3,000 for each child under the age of 19. This is for any accident resulting in death or dismemberment, it is not just snowmobile related. Please turn in your completed membership form and payment as soon as possible to ensure coverage!

The AWSC and DCCSC are dedicated to the success of Wisconsin snowmobiling and work for safe and responsible snowmobiling throughout the state. Web sites are www.danecountycouncilsnowmobileclubs.com

and www.awsc.org

Please mail your membership form and dues payable to County Line Sno Busters as soon as possible to:

County Line Sno Busters, c/o Carol Hollfelder

9570 Union Valley Road

Black Earth, WI 53515

Questions: phone 608-767-2441

email

Club website is: www.countylinesnobusters.com

Thank you for joining County Line Sno Busters snowmobile club!

County Line Sno Busters is a 501(C) 4 club. All dues are non-deductible. Donations/contributions to CLSB are not tax deductible by donors.