Membership Application

Print this form, fill in the information requested and mail with your membership dues to Freedom Chapter ABATE of Florida, Inc. Attn: Membership at  P O Box 10013, Brooksville, FL 34601.

NAME:

 ______________________________________________________________
MAILING ADDRESS:

 ______________________________________________________________
City:  ________________________

 State:  ___________ Zip+4    ___________________ Phone:  (_______)  _________________
E-MAIL ADDRESS:

 ______________________________________________________________
Do you wish to receive the newsletter by mail and not electronically?
YES:  ________

 NO:  ________ Signature:  __________________________________________________
If Member of more than one Chapter, please declare your Home Chapter.

 ______________________________________

Please Check the type of membership that appiles to you


_______ New Annual Membership ($20.00)


_______ Life Membership ($600.00)


_______ Transfer Membership from   Chapter:  _______________________________


_______ Change of Member Info


_______ Renewal, Prime Member ($20.00)

All members receive with their paid membership card, our bi-monthly newsletter, the State ABATE bi-monthly MASTERLINK magazine, chapter voting priviledges, and personal involvement in Statewide legislative actions and their freedom to ride.

Old Info

Name: _______________________________________

Address: _____________________________________

City: _________________________________________

State: ____________  Zip+4_________________

Phone: (________)______________________

E-Mail: ________________________________________

New Info

Name: _______________________________________

Address: _____________________________________

City: _________________________________________

State: ____________  Zip+4_________________

Phone: (________)______________________

E-Mail: ________________________________________


Created: January 2010