Please print application,
complete all information and forward with payment of dues to:
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 ABATE OF IOWA STATE WEB SITE