Must Be 21 Years of Age to Join.
Please Print This Application and Fill Out Clearly.
Date of Application: ____/____/____
Name:____________________________________________________
Nickname:"___________________________________________________"
Address:____________________________________________________
City:________________________ State:______ Zip:______________
Home Phone:(_____)______________ Work Phone:(_____)_______________
Email:____________________________________________________
Date of Birth:____/____/____ (Required to Process Application)
Change of Address: O Yes O No
Membership Cost: O New Member: $20 O Five Years: $75
O Renewal $20 Exp Date: ____/____
Are You A Registered Voter?: O Yes O No
Are You Motorcycled Endorsed?: O Yes O No
Referred By:____________________________________________________
Make checks payable to Cowlitz County ABATE and send with completed application to:
Cowlitz County ABATE, P.O. Box 328, Kelso, WA. 98626
OR, Drop off at the Sub Shop on 15th Ave. in Longview
-----------------------------------Do Not Write Below--------------------------------
Receipt
Date:____/____/____ Amount $:_________________
Received From:_______________________________________________________
Received By:_______________________________________________________