TABERG TRAIL BLAZERS, INC.

P. O. Box 25

Taberg, NY 13471

First Name {PRINT ONLY} ______________________________________________

Last Name _________________________________________________________

Street Address/PO Box ________________________________________________

State _______________________ Zip Code______________________

Family Membership Information

Spouse First Name ___________________ Last Name_________________________

Children under 18 that intend to register a sled ______________________________________________________________________

Phone # __________________________________

Email __________________________________{DMV Voucher, NYSSA News Letter and other information can be emailed}

( ) Annual club membership - $25.00

( ) Lifetime membership - $250.00

( ) NYSSA Trail Defender membership additional $20.00

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

If so, deduct $5 and enter name of Club____________________________________

Number of sleds I 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 issued (ex 07-140-B183):  ______________________________

Snowmobile Trail Land Owner ( )