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 ($25.00/year)

________

Check

________

Associate ($20.00/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#)______________________________ 

 
Dues are non-refundable and subject to change
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