P.O. Box 1120
Northville, New York 12134
First Name ( Print Only)_______________________________________
Last Name______________________________________________________________
Street Address/P.O.Box _________________________________________________
State ___________________________ Zip code ______________________________
Family Membership Information
Spouse first name _______________Last Name _____________________________
Children under 18 that intend to register a Sled
________________________________________________________________________
Phone #'s ______________________________________________________________
E-mail ( Use correct case and Print Clearly )
_______________________________________________________________________
Check Membership Type:
( ) Single membership $25.00
( ) Family Membership $ 35.00
Have you already paid NYSSA dues this season via another Club? _____________
If so ,deduct $5.00 and enter the name of the club. ________________________
Number of sleds I intend to register ________
( ) Twenty five cents of your $5.00 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 the box. Please note your, NYSSA dues remain $5.00
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For Club Use Only:
Blank Voucher ID # Issued_____________________
Snowmobile Trail Land Owner ( )