Membership Application ABATE for Missouri
(Please Check Boxes That Apply)
___Single $25.00 ___New ___Renewal Form of payment_________________
___Couple $45.00 ___New ___Renewal Form of payment_________________
Payment Date____________
Remit Payment to: ABATE for Missouri * 2309 N. East Street Kirksville,Mo. 63501
PLEASE PRINT LEGIBLY
Name (1)
____________________________________________________________________________
Name (2)
____________________________________________________________________________
Address
____________________________________________________________________________
City________________________ State____________ Zip____________
County___________________
E-Mail (1)____________________________________________________________________
E-Mail (2)____________________________________________________________________
I prefer to receive my newsletter (Circle One) via E-MAIL or US MAIL
I understand that ABATE for Missouri, Inc. can not 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 for Missouri, Inc. harmless for any
injury or loss of my personal property which may result therefore. I understand this means that I agree not to sue
ABATE for Missouri, Inc. for any injury resulting to my self or my property at any event.
I agree to comply with the bylaws and act in the best interest of ABATE for Missouri, Inc.
Signature (1)______________________________________________ Date__________
Signature (2)______________________________________________ Date__________
____________________________________________________________________________________
You will receive a membership card and a ABATE for Missouri patch. Also $5.00 off at any ABATE event