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Chickawaukie Ice Boat Club

Membership Application Form

Year ____________

Please complete form below and mail with $20 cash or check.

Chickawaukie Ice Boat Club
Jim Gagnon,Treasurer
PO Box 463
West Boothbay Harbor, ME 04575

Name_______________________________________________________

Address_______________________________________________________

Email_______________________________________________________

Home Phone _____________________________________________________

Cell Phone _______________________________________________________

BoatType______________________________________________________

SailNumber____________________________________________________

Membership Status: Returning____ New____

Annual dues $20

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