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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:_________________________________________
Name
(1)__________________________________________________________
(2)_______________________________________________
Address
____________________________________________________________________________________________________________
City
______________________________________________________________________________State
__________ Zip _______________
Email address_______________________________________________________________________
Phone (______)
____________________ County _______________________ Registered Voter
(1) YES NO (2)
YES
NO
Congressional
Dist. ______________ Senatorial Dist. ____________ Representative Dist.
____________
Date of Birth
(1)________________ (2)_______________ Occupation
(1)__________________________(2)___________________________
Completed a
MSF Course (1) YES NO (2) YES NO
Where did you hear about ABATE?
_______________________________________
AMOUNT
$____________Check
Enclosed. CHARGE
TO: c
Visa c MasterCard
c
Discover Expiration Date:___________
CARD
NUMBER:__________________________________________
Signature:_______________________________________________
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: DuKane Chapter A.B.A.T.E. of Illinois~ PO Box 188, West Chicago, IL 60186
MUST BE 18 TO JOIN (309) 343-6588 ~~
800-87-ABATE ~~ FAX: (309) 343-6387
I understand that ABATE
of Illinois cannot assume responsibility for my safety and that if I
participate in any sanctioned event,
I do so
voluntarily, assuming all risk; I release and hold ABATE harmless for any
injury or loss to my personal property
which may result
therefrom. I understand this means that I agree not to sue ABATE for
any injury resulting to myself or
my property at any event.
I agree to comply with the Bylaws and act in the best interest of
A.B.A.T.E. of Illinois.
A copy of ABATE-PAC's
report is or will be filed with the State Board of Elections, Springfield,
Illinois.
Signature(s)
(1)________________________________________(2)_____________________________________ | 
