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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