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Membership Officer John Ucthman

Membership Status

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: ______ 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

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