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ABATE OF FLORIDA, INC. Independence Chapter PO Box 410932 |
AMERICAN |
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1-year Membership 2nd Person in same household **LIFE** Membership |
$20.00 $15.00 $150.00 |
DATE ___________ CHECK # ________CASH ________ |
MEMBER
#_____________________
NEW EXPIRATION ______________ |
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NEW _____ |
LIFE _____ |
RENEWAL _____ |
TRANSFER _____ |
CHANGE OF INFO _____ |
D.O.B. _________ |
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NAME____________________________________________ |
HOME PHONE #_________________ | ||
| STREET___________________________________________ | CELL PHONE #__________________ | ||
| CITY ______________________ | ST ____ | ZIP ________ | PAGER # _______________________ |
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COMPLETE M.S.F. COURSE _____ |
OCCUPATION ___________________________ | ||
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REGISTERED VOTER |
YES ___ |
NO ___ |
IF NO, WILL YOU REGISTER TO VOTE? _______ |
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FLORIDA LEG. DIST. |
HOUSE # _____ |
SENATE # _____ |
U.S. HOUST DIST. # ________ |
WHAT CAN YOU DO TO HELP OUR CAUSE? (Circle) TIME, LABOR, MONEY, LOBBYING, VOTING, COMMITTEES)
Email Address:______________________________________________________________________________________
REFERRED BY INDEPENDENCE CHAPTER MEMBER Cindi Odom
Revised
6/20/99
Card Mailed
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Computer Updated ______________ Entered on
Form ____________
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(Print form, fill out, mail/ give to chapter officer with membership dues) |