Address:________________________________City:__________________County:_________________

State:______Zip:______________Phone:______________________Birthdate:____________________

M/F:___Year pin needed (1st, 2nd, etc.):_____Chapter:___________Origination Date:_______________

E-mail address:______________________________________ May we send e-mail info? Yes __ No __

In consideration of acceptance of the application, I hereby agree to waive any and all claims against ABATE, it's officers, board members, and general members for loss or damage which may occur to me or my property as a result of my participation in ABATE functions. I understand that ABATE cannot and will not assume responsibility for any aspect of my safety and that, if I participate in any ABATE sponsored ride or event, I do so voluntarily on my own assessment of my ability, to course, and all conditions, assuming all risks, and I release and hold ABATE harmless for any injury or loss to my person or property which may result therefrom. I further agree not to sue ABATE or any property owner on whose property such injury or damage may occur in any court of law for any injury to myself or my property and I agree to reimburse ABATE for any and all losses it may suffer as a result of my own or guests' participation in any ABATE sponsored event.

Signature of applicant___________________________________________Date__________________

Signature of responsible party if not of legal age________________________________________

You may print out and mail this application to the above address with your payment to become a member of A.B.A.T.E. of Mississippi, Inc.