A.B.A.T.E. OF ILLINOIS MEMBERSHIP APPLICATION

New Member (1)____ (2)____ Renewal (1)_____ (2)_____ Card# (1)_________(2)__________Date _________ Original Date Joined (if renewal) (1)_______(2)________ Chapter Preference _____Arrowhead Valley   _____

Name (1)_____________________________ (2)_____________________________

street_________________________city______________State _____Zip ________

Phone (___) _________ County ___________Registered Voter (1)____ (2)___

Congressional Dist. ____ Senatorial Dist. ____ Representative Dist. ____ Blood Type (1)______( 2)_____

Date of Birth (1)________ (2)_________Occupation (1)____________ (2)___________ Completed a MSF Course (1)___(2)____ Where did you hear about ABATE? ______________________________

MEMBERSHIP & RENEWAL FEES: [  ] $25.00 PER YEAR SINGLE [ ] $45.00 PER YEAR COUPLE

MONEYSAVER SPECIAL: [  ] $100.00-5 YEARS/SINGLE [  ] $180.00 5 YEARS/COUPLE

ABATE-PAC SUPPORT: [  ] Add $1.00 per yr. to dues amount to support legislative contributions. **$2. of members dues is allocated to lobbying expense & $1. is donated to Motorcycle Riders Foundation.MAKE CHECK PAYABLE & MAIL TO: Arrowhead Valley, P.O. Box 269 Bradley, IL 60915 .

Signature(s)
(1)_________________________(2)________________________