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 #)____________________