ABATE of New York, Inc

Long Island Chapter

MEMBERSHIP FORM MAIL TO : ABATE of LONG ISLAND P.O. BOX 1311, RIVERHEAD, N.Y. 11901 Full Member: $25.00 Per Year - Includes Membership Patch, Newsletter And All Benefits In Accordance With State Laws. Associate Member: $20.00 Per Year - Same Benefits, Except No Newsletter, This Is Available Only To Additional Members Of Full Members Households.  NAME:______________________________ DATE OF BIRTH: ________ CHAPTER:_________________ ADDRESS:___________________________ CITY:___________________________ STATE:_____________ ZIP:____________ COUNTY: _______________________ PHONE: [_____]______________________ EMAIL :_________________________ VISA: MASTERCARD: NAME ON CARD: ______________________________ NUMBER: _____________________________________ EXP. DATE _____________ I agree to comply with ABATE of New York's by-laws, and promote motorcycle education, legislation, and activities in accordance with ABATE of New York. DATE:___________________________ APPLICANT'S SIGNATURE____________________________________ NEW:  RENEW:  PIN DUE:  PATCH DUE:  YEAR:___  MEMBER#:______ SIGNED BY:_________________________

 

 

MEMBER'S RECEIPT DATE:________________                                                         RECEIVED FROM:__________________ASSIGNED #:_______ APPLICANT'S NAME:_________________________________ 1 YEAR MEMBERSHIP ____________ TO_________________ $25.00 FULL MEMBER $20.00 ASSOCIATE MEMBER CHAPTER:__________________________________________ ACCEPTED BY:________________ NAME:_____________________________________________ ABATE of LONG ISLAND P.O. BOX 1311 RIVERHEAD, N.Y. 11901   PLEASE RETAIN THIS RECEIPT AS PROOF OF APPLICATION & PAYMENT. MAY BE USED AS TEMPORARY PROOF OF MEMBERSHIP UNTIL MEMBERSHIP PACKET & PERMANENT CARD IS RECEIVED.