Membership Application












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                       (Please Print legibly)   
                                                      New member__
 Single                  Couple                 Renewal Yr____ 
 one year--$25.00    one year---$40.00    
  
Junior------$7.50           Donation Optional $______
 
M/C owner....yes__  No__ M/C Endorsement...yes_ no_
 
Registered Voter.... Yes__  No__
 
Sex......Male___ Female__
 
Birthdate.._____/____/______
 
Expiration date_____________
 
Rec'd Patch or Pin.... Yes__No___
                           

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Name______________________________________                                         
 
Address_____________________________________
 
City________________________________________
 
State___________________ Zip_______________
 
County________________________________
 
Region__________________________________
 
Chapter__________________________________
 
Phone______________________________
 
E-Mail_______________________________
 
Signed-up By_______________________________
 
Dues include membership card and 6 issues of The Biker Bulletin Newsletter
 
 
Please make checks payable to : A.B.A.T.E. of WV
 
Include check with application.
Mail to:
 
The Mountaineer Chapter of  A.B.A.T.E.
c/o Lola Crist
      P.O. Box 13
      Burnsville, W.V. 26335
    

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