MEMBERSHIP APPLICATION

FOR NEW MEMBERS AND RENEWING MEMBERS

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 Type of Membership:

_ New Member __ Full ($25.00/year)

_ Renew Membership __ Associate ($20.00/year)

_ Address Change __ Life ($300.00)

__ Supporting Business ($50.00/year)

__ Supporting Organization ($100.00/year)

Type of payment

. Check

. Money Order

. ABATE Bucks

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 Code: ______________________________________________________

Email Address: ________________________________________________________

Are you a registered voter? _______________

Do you object to having $2.00 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.)

Would you like to receive an ABATE patch? Yes ______ No _____

(New Full & Life Members Only. Does not apply to associate or supporting business memberships.)

Applicants Signature: ______________________________________________________

Date: _________________________

Recruited by: (card #)____________________