Please print application, complete all information and forward with payment of dues to:
ABATE of Iowa, Inc.,
PO Box 70,
Eldora, IA 50627
641-858-5001
Type of application:
______ NEW
MEMBER
______ RENEWAL
______ Address Change
Type of membership: Type of payment:
______ Full ($20.00/year)
_______Check
______ Associate ($15.00/year) _______Money Order
______ Life ($300.00) ______ABATE Bucks
_______Supporting Business ($50.00/year)
______ Supporting Organization ($100/year) Note: Dues are
non-refundable and subject to change
Amount Enclosed:_______________
District #_____ Card #_____________ Phone # (_______)___________________
Name ________________________________________________________________
(name is required for all members – one name only, no couple memberships)
Supporting Business ____________________________________________________
Mailing Address _______________________________________________________
City _______________________________ State _____ Zip ________
E-Mail Address ____________________________________
Are you a registered voter? Yes____ No____
Do you object to having $1.00 of your dues donated to ABATEPAC? Yes __ No __ (It is illegal to deposit money in a PAC from a corporate check. Please use personal checks.)
New Full and Life members only:
Would you like to receive an ABATE patch? Yes___ No___
(Does not apply to associate or supporting business
memberships.)
Applicant’s
Signature:_______________________________ Date______________
Recruited by Mike Stone # 20976