MEMBERSHIP APPLICATION
MAD. HILL RIDERS ATV. CLUB Inc.
3876 Sanderson Rd. Erieville, NY 13061
E-MAIL: madhillriders@hotmail.com
NEW MEMBERHIP____ RENEWAL ____
SINGLE MEMBERSHIP $20.00 ______ (Family/Domestic partner membership
FAMILY MEMBERSHIP $30.00 ______ includes up to four machines, primary
BUSINESS MEMBERSHIP $60.00 ______ member must be 18 yrs.)
NAME ___________________________________
ADDRESS _______________________________
CITY _________________________ STATE ________ ZIP CODE ______________
PHONE ________________________ EMAIL ________________________________
MAKE __________ MODEL __________ YEAR ________ LIC. # __________
MAKE __________ MODEL __________ YEAR ________ LIC. # __________
MAKE __________ MODEL __________ YEAR ________ LIC. # __________
MAKE __________ MODEL __________ YEAR ________ LIC. # __________
Insurance Carrier __________________________________________________
I verify that the above information is correct and I have read, understand, and will abide by
the club by-laws. _______________________________________________________
***** Official Us Only ***** Official Use Only*****
Date __________ Amount __________ Check # __________ Cash __________
Insurance _____ Registration _____
APPLICATIONS WILL NOT BE PROCESSED WITHOUT PRIOR DOCUMENTATION
PROOF OF REGISTRATION AND INSURANCE REQUIRED
(Highlight and print application)
