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ON-LINE APPLICATION FORM Hi! You've come to this page because you must be at least a little interested in finding out more about ABATE of Illinois, its mission, members' services, and benefits. Once you have decided to take the plunge, just print out this form, fill in the information as well as you can (Don't sweat it if you don't know your legislative stuff), and mail it to the address listed at the bottom of the form. --------------------------print this form and mail-in-------------------------- 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 ______________________________________ 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 TO: ABATE of Illinois MAIL TO: ABATE of Illinois, 311 E. Main Street, Suite 418, Galesburg, IL, 61401 MUST BE 18 TO JOIN 800-87-ABATE (State number) 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)_____________________________________ |
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