A.B.A.T.E. of  ILLINOIS  MEMBERSHIP  APPLICATION
New Member (1)_____ (2)_____  Renewal (1)_____ (2)_____  Membership # (1)__________ (2)__________  Date___________

Original Date Joined (if renewal)  (1)________ (2)________  Chapter Preference_Crawford County______________________

Name (1)_________________________________________________ (2)___________________________________________

Address _________________________________________________ City ___________________________________________

State______________ Zip______________  Phone (______) ___________________ County____________________________

E-Mail address (1)_____________________________________(2)________________________________________________

Congressional District __15__ Senatorial District __55__ Representative __109___  Registered Voter (1)________ (2)_________

Date of Birth (1)_____________ (2)_____________ Occupation (1)_______________________ (2)________________________

Completed a MSF Course (1)______ (2)______ Where did you hear about ABATE? CC ABATE web site___________________

MEMBERSHIP & RENEWAL FEES:
***   $2 OF EACH MEMBERS DUES IS ALLOCATED TO LOBBYING EXPENSE.   ***
______________________________________________________________________________________________________
MAKE CHECKS PAYABLE & MAIL TO:   CRAWFORD COUNTY A.B.A.T.E.    PO BOX 731      ROBINSON, IL  62454
Signatures (1)_________________________________________ (2)______________________________________________
Amount $_______________  [  ] Check enclosed   Charge to:   [  ] Visa      [  ] Mastercard      [  ] Discover     Exp.Date____________

Card Number_________________________________________ Signature__________________________________________

(Credit Card Registrations can be faxed to A.B.A.T.E. @  309-343-6387)
[  ]   $25.00 PER YEAR SINGLE               [  ]   $45.00 PER YEAR COUPLE
[  ]   $100.00 - 5 YEARS / SINGLE           [  ]   $180.00 - 5 YEARS / COUPLE
[  ]  Add $1.00 per year to above dues amount to support legislative contributions
I understand that A.B.A.T.E. 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 A.B.A.T.E. harmless for any injury or loss to my personal property which may result there from.  I understand this means that I agree not to sue A.B.A.T.E. 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, IL.
Please print this form off, fill in the information and mail it to the address on the application.