Please complete all information, print application, sign and forward with payment of dues to: ABATE of Iowa, Inc., P.O. Box 70, Eldora, Iowa 50627-0070
Type of Application NEW (have not previously been a member) or (prefer to start over rather than re-join) RE-JOIN (membership has lapsed; payment enclosed will bring membership up-to date) RENEWAL (for members who are current in their membership) ADDRESS CHANGE
Type of Membership FULL ($20/year per person) ASSOCIATE ($15/year per person) LIFE ($300) SUPPORTING BUSINESS ($50/year) SUPPORTING ORGANIZATION ($100/year)
Type of Payment Check Money Order ABATE Bucks
Amount Enclosed $
District # Card # Phone #
Name
Supporting Business Name
Mailing Address
City State Zip
Email address
Are you a registered voter? Yes No
Do you object to having $1.00 of your dues donated to ABATEPAC? Yes No
New Full and Life Members only: Would you like to receive an ABATE patch? Yes No
Recruited BY
Are they a Current Member Yes No Their Member Card #
Applicant's Signature: _____________________________ Date: _________________