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A.B.A.T.E. of Kansas, Inc. Membership Application Return Application to A.B.A.T.E. of Kansas, Inc. P.O. Box 102, Perry, KS 66073 Date __________________ Dist# _________________ q New Member $30 q Couple $50 q Renewal Ind/Cpl Mbr#_____________________________ q Life Member $300 q Change of Address q Change of District q Registered Voter Please Print Clearly Full Name _____________________________________________________________________________________________ Full Name _____________________________________________________________________________________________ Address / Apt#______________________________________________________ County _____________________________ City _______________________________________________ State ______________________ Zip __________________ E-Mail ___________________________________________________________ Phone______________________________ Newsletter: q Mail q E-Mail Referred By _______________________________________________________________ Applicant’s Signature _____________________________________________________________________________________ Payment Type: q Cash q Check Amount $____________ Check #___________ Revised April 2017 A.B.A.T.E. of Kansas, Inc. P.O. Box 102, Perry, KS 66073 (785) 597-5140 (800) 657-5763 Date ______________________________ Exp ______________________________ q Renewal q New q Couple q Life q Business Bronze q Business Silver q Business Gold Applicant ___________________________________ Received By _________________________________ Receipt for applicant Fees are not tax deductible.
