Name:_____________________________   ______________  _______________________________________________
                      Last                                                                               First                                     Spouse or Significant Other
Mailing Address:___________________________________________  ______________________ ________ __________
                                                    Street                                                                                                             City/Town                                    State                     Zip

Home phone  _____________ work phone _____________  email: ______________________

Additional address: _________________________________Additional phone___________________________

QUESTIONNAIRE:

If you are on a lake or pond which one? ____________                      What special skills do you have? ___________________

May we call you for work parties? Yes____No_____                         May we call you to help groom? Yes_____No______

  Please circle your selection(s):

CLUB MEMBERSHIP   Dues:                                                    $35.00            If you belong to another club   $25.00 (does NOT include NHSA)  Fill in >>>>>>>>>>>>> $35 Club Membership includes 1 free decal, NHSA membership and Sno-Traveler newspaper. Club name:                                                       Membership number: CLUB MATERIAL Jacket Patch:  $3.00 x____=            $______  Club Decal    $2.00 X ____=            $_______ GROOMER FUND DONATION:  $ _________ For the exclusive purpose of purchasing grooming equipment. BUILDING FUND DONATION:    $ _________ Enhancements, additions to building and grounds. EASTER SEALS  DONATION:    $_________ Benefits Camp Sno-Mo for Easter Seals kids. NHSA sponsored charity. Total Enclosed:                      $ ______________ We thank you for your membership and any donations you may make.