ABATE of Virginia - Membership Application

Print this page, fill out the form, & mail with your check or money order to:

                                                    ABATE of Virginia
                                                    PO Box 426
(Please print all information legibly.)             Oakton, VA 22124

Date: ___ /___ / 20___

Name (1): ___________________________  Signature (1): _______________________

Name (2): ___________________________  Signature (2): _______________________

Address: _____________________  City: ______________  State: __  Zip: _______

Referred By: (Name)_____________________________  (Chapter)__________________

Occupation: _________________  Phone: ____________  E-mail: _________________	

                Application Type:  O New
                                   O Renew   Chapter ______________________

                Have Pickup Truck? O Yes     AMA Member? O Yes # __________
                                   O No                  O No 

                VCOM Member?       O Yes     MRF Member? O Yes
                                   O No                  O No 

What would you like ABATE to accomplish?  (We do read this)

_____________________________________________________________________________

_____________________________________________________________________________

Personal Membership:                          Single       ($ 20.00) ________

 - Add $10.00 for each additional             Joint        ($ 30.00) ________
   member in the same household
                                              x3 Years     ($______) ________

Business Sponsorship:                         Platinum     ($300.00) ________

                                              Gold         ($200.00) ________

                                              Silver       ($100.00) ________

Donation:                                     VCOM         ($ 10.00) ________

Amount Enclosed .................................................... ________
   (Dues/donations are not tax deductable, transferrable, or refundable.)