Brunswick County Chapter
Concerned Bikers Association/ABATE Of NC, INC.
APPLICATION FOR MEMBERSHIP

(Print this page OR use the Word Document)

PLEASE PRINT OR TYPE YOUR INFORMATION          

NAME (S) _________________________________________________     _______________________________________________

ADDRESS___________________________________________________________________________________________________

CITY____________________________________________ STATE____________ ZIP CODE______________________________

PHONE (           ) _________________________ E-MAIL ADDRESS___________________________________________________

OCCUPATION________________________________________________________________ AGE__________________________

MAKE/SIZE OF MOTORCYCLE___________________________________ MILES PER YEAR____________________________

    ARE YOU AFFILIATED WITH ANY OTHER MOTORCYCLE ORGANIZATIONS?     Yes _____No______

If yes, name__________________________________________________________________________________________________

ARE YOU A REGISTERED VOTER?       Yes______ No_______

I UNDERSTAND BY SIGNING MY NAME TO THIS APPLICATION THAT I AM SEEKING MEMBERSHIP INTO A GRASSROOTS POLITICAL ORGANIZATION FORMED TO PROTECT MOTORCYCLIST’S RIGHTS.

SIGNED: ___________________________________________________________________________________________________

RECRUITED BY_____________________________________________________________________________________________

     ______$25.00 annual individual membership         ______$35.00 annual couple membership 

        ______$20 renewal individual membership              _____ $30 renewal couple membership

Chapter Affiliation_________________________ (or) you may join as an “At Large” member_________

Mail your completed application with payment to above address.

 For more information on chapters and the CBA organization, visit www.cba-abatenc.org