ABATE OF LOUSIANA MEMBERSHIP APPLICATION

NEW MEMBERSHIP: (circle one)
$20.00 New Member
$5.00 Youth

LIFETIME MEMBERSHIP:
$150.00 Single
$225.00 Couple

RENEWAL: (circle one)
$20.00 Single
$5.00 Youth

Make check or money order payable to:
A.B.A.T.E. of Louisiana, Inc.

Send completed application with dues to:

A.B.A.T.E. of LA, Inc
P.O. Box 541 .
St. Amant, La. 70774

PLEASE PRINT ALL INFORMATION!

NEW:_________RENEW :_________

DATE:_____________

NAME:______________________________________

ADDRESS:___________________________________

CITY :____________________________________STATE:___________ZIP:_______________________

PHONE:_____________________

EMAIL:__________________________________________

DATE OF BIRTH:__________________________________

OWN AN M/C:_______

VOTER REG. CARD #:________________________________________

HOUSE DIST:__________________SEN. DIST:__________________

CONGRESSIONAL DIST:________________

WARD/PREC:______________

EMERGENCY CONTACT NAME:___________________________PHONE#:____________________

CHAPTER:____________________________________

AMOUNT ENCLOSED: $_________

REFERRED BY:______________________________________________

LEGISLATIVE DONATION (OPTIONAL) __________$5.00 ____________$10.00 ______________OTHER

I agree to comply with A.B.A.T.E. rules for motorcycle events. I understand that all benefits become effective upon receipt of my membership card. I agree not to hold A.B.A.T.E. responsible for accidents that may occur at A.B.A.T.E. events. Membership dues and donations are NOT tax deductible for federal income tax purposes.

Signed ___________________________________________