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Brunswick
County Chapter
Concerned Bikers
Association/ABATE Of NC, INC.
APPLICATION FOR MEMBERSHIP
(Print this page)
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
______$25 renewal individual membership _____ $35.00 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
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MEMBERSHIP SERVICES ONLY:
faxed date:___________
postmarked date:___________ received date:___________
date sent to chapter:____________
Check #
___________ Amount: ____________ expiration date:
______________ (or) new start date_________________ |
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