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First Name
Last Name
Email
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Mobile Phone
Work Phone
Prefered Phone
Home
Work
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Address
Address Line 1
Address Line 2
City
State/Province/Region
Postal Code
Country
UNITED STATES
ASCENSION ISLAND
AFGHANISTAN
ALAND
ALBANIA
ALGERIA
ANDORRA
ANGOLA
ANGUILLA
ANTARCTICA
ANTIGUA AND BARBUDA
ARGENTINA REPUBLIC
ARMENIA
ARUBA
AUSTRALIA
AUSTRIA
AZERBAIJAN
BAHAMAS
BAHRAIN
BANGLADESH
BARBADOS
BELARUS
BELGIUM
BELIZE
BENIN
BERMUDA
BHUTAN
BOLIVIA
BOSNIA AND HERZEGOVINA
BOTSWANA
BOUVET ISLAND
BRAZIL
BRITISH INDIAN OCEAN TERR
BRITISH VIRGIN ISLANDS
BRUNEI DARUSSALAM
BULGARIA
BURKINA FASO
BURUNDI
CAMBODIA
CAMEROON
CANADA
CAPE VERDE
CAYMAN ISLANDS
CENTRAL AFRICAN REPUBLIC
CHAD
CHILE
PEOPLE’S REPUBLIC OF CHINA
CHRISTMAS ISLANDS
COCOS ISLANDS
COLOMBIA
COMORAS
CONGO
CONGO (DEMOCRATIC REPUBLIC)
COOK ISLANDS
COSTA RICA
COTE D IVOIRE
CROATIA
CUBA
CYPRUS
CZECH REPUBLIC
DENMARK
DJIBOUTI
DOMINICA
DOMINICAN REPUBLIC
EAST TIMOR
ECUADOR
EGYPT
EL SALVADOR
EQUATORIAL GUINEA
ESTONIA
ETHIOPIA
FALKLAND ISLANDS
FAROE ISLANDS
FIJI
FINLAND
FRANCE
FRANCE METROPOLITAN
FRENCH GUIANA
FRENCH POLYNESIA
FRENCH SOUTHERN TERRITORIES
GABON
GAMBIA
GEORGIA
GERMANY
GHANA
GIBRALTER
GREECE
GREENLAND
GRENADA
GUADELOUPE
GUAM
GUATEMALA
GUINEA
GUINEA-BISSAU
GUYANA
HAITI
HEARD & MCDONALD ISLAND
HONDURAS
HONG KONG
HUNGARY
ICELAND
INDIA
INDONESIA
IRAN, ISLAMIC REPUBLIC OF
IRAQ
IRELAND
ISLE OF MAN
ISRAEL
ITALY
JAMAICA
JAPAN
JORDAN
KAZAKHSTAN
KENYA
KIRIBATI
KOREA, DEM. PEOPLES REP OF
KOREA, REPUBLIC OF
KUWAIT
KYRGYZSTAN
LAO PEOPLE’S DEM. REPUBLIC
LATVIA
LEBANON
LESOTHO
LIBERIA
LIBYAN ARAB JAMAHIRIYA
LIECHTENSTEIN
LITHUANIA
LUXEMBOURG
MACAO
MACEDONIA
MADAGASCAR
MALAWI
MALAYSIA
MALDIVES
MALI
MALTA
MARSHALL ISLANDS
MARTINIQUE
MAURITANIA
MAURITIUS
MAYOTTE
MEXICO
MICRONESIA
MOLDAVA REPUBLIC OF
MONACO
MONGOLIA
MONTENEGRO
MONTSERRAT
MOROCCO
MOZAMBIQUE
MYANMAR
NAMIBIA
NAURU
NEPAL
NETHERLANDS ANTILLES
NETHERLANDS, THE
NEW CALEDONIA
NEW ZEALAND
NICARAGUA
NIGER
NIGERIA
NIUE
NORFOLK ISLAND
NORTHERN MARIANA ISLANDS
NORWAY
OMAN
PAKISTAN
PALAU
PALESTINE
PANAMA
PAPUA NEW GUINEA
PARAGUAY
PERU
PHILIPPINES (REPUBLIC OF THE)
PITCAIRN
POLAND
PORTUGAL
PUERTO RICO
QATAR
REUNION
ROMANIA
RUSSIAN FEDERATION
RWANDA
SAMOA
SAN MARINO
SAO TOME/PRINCIPE
SAUDI ARABIA
SCOTLAND
SENEGAL
SERBIA
SEYCHELLES
SIERRA LEONE
SINGAPORE
SLOVAKIA
SLOVENIA
SOLOMON ISLANDS
SOMALIA
SOMOA,GILBERT,ELLICE ISLANDS
SOUTH AFRICA
SOUTH GEORGIA, SOUTH SANDWICH ISLANDS
SOVIET UNION
SPAIN
SRI LANKA
ST. HELENA
ST. KITTS AND NEVIS
ST. LUCIA
ST. PIERRE AND MIQUELON
ST. VINCENT & THE GRENADINES
SUDAN
SURINAME
SVALBARD AND JAN MAYEN
SWAZILAND
SWEDEN
SWITZERLAND
SYRIAN ARAB REPUBLIC
TAIWAN
TAJIKISTAN
TANZANIA, UNITED REPUBLIC OF
THAILAND
TOGO
TOKELAU
TONGA
TRINIDAD AND TOBAGO
TUNISIA
TURKEY
TURKMENISTAN
TURKS AND CALCOS ISLANDS
TUVALU
UGANDA
UKRAINE
UNITED ARAB EMIRATES
UNITED KINGDOM
UNITED STATES MINOR OUTL.IS.
URUGUAY
UZBEKISTAN
VANUATU
VATICAN CITY STATE
VENEZUELA
VIET NAM
VIRGIN ISLANDS (USA)
WALLIS AND FUTUNA ISLANDS
WESTERN SAHARA
YEMEN
ZAMBIA
ZIMBABWE
Chapter
Chapter:
ACBS ($0)
Adirondack (NY) ($15)
Allegheny (PA) ($15)
Bay State Classic Boat Club (MA) ($25)
Bayou Chapter (LA, MS, AL) ($15)
Big Sky Chapter (MT) ($20)
Blackhawk (IL, WI) ($20)
Blue Ridge (NC, SC, GA) ($20)
Buckeye (OH) ($15)
Chautauqua Lake Twin Tier (Northwest PA, Southwest NY) ($25)
Chesapeake Bay (DE, DC, MD, VA) ($25)
Columbia Willamette (OR, South WA) ($30)
Dixieland (AL, MS, LA, KY, TN) ($15)
Finger Lakes (east of Seneca Lake NY) ($25)
France ($30)
Glacier Lakes (WI) ($25)
Heartland Classics (OK, KS, NE, MO, AR) ($35)
Hudson River (East NJ, Hudson Valley NY) ($20)
Indian Lake (OH) ($25)
Indiana ($20)
Inland Empire (North ID, Eastern WA, West MT) ($25)
Jerry Dyhrkopp/Iowa Great Lakes (IA) ($15)
Lake Champlain (VT, NY) ($25)
Lake Hopatcong (North NJ) ($25)
Land-O-Lakes Classic Boat Club (MN, ND, SD) ($25)
Long Island (southeast NY) ($20)
Manotick (East ON, QC) ($15)
Michigan (eastern MI) ($35)
Mid-Atlantic Chapter (southeast PA, southern NJ) ($25)
Mississippi Valley (AR, eastern KS, MO, southern IL) ($25)
Mountainview Woodies Classic Boat (ME) ($25)
NC Coastal & Piedmont (NC) ($20)
New England (NH, VT) ($30)
Niagara Frontier (western NY, southern ON) ($25)
North Coast Ohio (OH) ($20)
Northern California/Lake Tahoe (CA) ($35)
Northern Europe ($0)
Ohio Valley Chapter (southwest OH) ($15)
Pacific Northwest (WA) ($25)
Payette Lakes (central and southern ID) ($30)
Penn NE/Harveys Lake (northeast PA) ($15)
Rocky Mountain Classics (Colorado & vicinity) ($25)
Smith Mountain Lake (southwest VA) ($20)
Southern California (Fresno and south CA, AZ) ($30)
Southern New England (CT, RI, southern MA) ($25)
Southwest (TX, NM) ($25)
Sunnyland (FL) ($25)
Thousand Islands (St. Lawrence River NY, ON) ($15)
Tidewater (southern VA and northern NC) ($15)
Toronto (ON) ($60)
Water Wonderland (western and northern MI) ($25)
Western Canadian (BC, AB, SK ) ($25)
Wine Country (west of Seneca Lake NY) ($25)
Note: Only Mastercard, Visa and Discover credit cards are accepted for payment.
Credit Card Payment
Total Amount
Name on card
Credit Card Number
Expiration
Month
Jan (01)
Feb (02)
Mar (03)
Apr (04)
May (05)
Jun (06)
Jul (07)
Aug (08)
Sep (09)
Oct (10)
Nov (11)
Dec (12)
Year
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
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