***To print this application click on "File" and "Print" in your browser.***
Membership Application
to ABATE of Oregon, Inc.
Southeast Chapter
Is this a new membership? _____ Have you received your membership patch? ______
If you are renewing your membership what is your membership number? ___________
What is your name? _____________________________________
What is your address, city, state & zip? __________________________________________
What is your phone number? ________________________
What is your e-mail address? ___________________
Do
you want membership for additional people in the same household? Yes - No
This means spouse, children or "significant other"
NOT roommates,
insignificant others or simply people you hang out with.
What are their names? _______________ __________________ _________________
Membership Requested ~ Please Circle One: $20 Single ~ $25 Couple ~ $30 Family
Total number of new members: ______ Total number of renewals: _______
Additional donation to SE Chapter programs: $__________
Total Amount Enclosed: $____________
Voting District: Congressional _______ Senatorial_______Representative_______
Mail to:
Membership
Secretary
ABATE of Oregon, Inc.
PO Box 4504
Portland, OR 97208