MEMBERSHIP APPLICATION
Please print application, complete all information and forward with payment of dues to: ABATE of Iowa, Inc., P.O. Box 70, Eldora, Iowa 50627
| Type of application: | |
| ________ | NEW |
| ________ | 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 ($100.00/year) |
Amount Enclosed: ______________
District # 10 Card # _________ Phone # (____) ____________________
Name ____________________________________________________________
(name is required for all members)
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 ____
Applicant's Signature: ___________________________ Date: _____________
Recruited by (card#)______________________________