Please Complete This Application And Return With Payment To:

ABATE of Kansas. Inc., P.O. Box 102, 610 Elm, Perry KS 66073

Membership in ABATE of Kansas is $25 per person. Life $500 as of January 1, 2007

PLEASE PRINT CLEARLY:

Date ______ Renew ______ New ______ Life ______ Address Change ______

Card# ______ District ______

Signed up: From ABATE of Kansas District 3 Web Page

Full Name: __________________________________________________________

Address: ___________________________________________________________

City ____________ State ______ ZipCode________ County ____________

Phone (Area Code)__________________ Nickname __________________

Are you a registered voter?______ County ____________

Have you taken a M/C riders course?____________

Are you interested in taking a M/C course? ____________

MEMBERSHIP FEES ARE NOT TAX DEDUCTABLE