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Contact Information First Name Last Name Street Street 2 City Country Please select… Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos ( Keeling ) Islands Colombia Comoros Congo Cook Islands Costa Rica Côte d ‘ Ivoire Croatia ( Hrvatska ) Cuba Cyprus Czech Republic Congo ( DRC ) Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands ( Islas Malvinas ) Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao SAR Macedonia, Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Samoa San Marino São Tomé and Prìncipe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Kitts and Nevis St. Lucia St. Pierre and Miquelon St. Vincent and the Grenadines Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Viet Nam Virgin Islands ( British ) Virgin Islands Wallis and Futuna Yemen Zambia Zimbabwe State Please select… Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Province Please select… Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Zip/Postal Code Email Phone Choose Your Membership Level Individual Membership – 1-year membership – $35Individual Membership – 2-year membership – $60Student/Senior Membership – 1-year membership – $25Sustaining Membership – 1-year Sustaining Membership – $100Jersey Club Membership – 1-year Jersey Club Membership – $500Membership & Additional Donation – 1-year Membership ($35) + Make this an autorenewing membership for $30/year Make this an autorenewing membership for $25/year Make this an autorenewing membership for $100/year Make this an autorenewing membership for $500/year Members who join with a contribution of $100 or more will receive a WABA t-shirt Choose your t-shirt size, or select “None” Please select… S M L XL None Members who join with a contribution of $500 or more will receive a WABA jersey Choose your jersey size, or select “None” Please select… XS S M L XL 2XL 3XL None Donation Amount Credit Card Information Name on Card Card Number MM YY Code Please Choose Your Contact Options WABA sends current members bi-annual appeal letters and quarterly paper newsletter called RideOn If you do not select one of the three options below, WABA will send you all print mailings and a paper copy of RideOn. Manage your email subscriptions here: Please only contact me by email including an email version of RideOnPlease don’t send me print mailing except a paper version of RideOn Additional Contact Preferences Please don’t call me. Thanks.Please send me print mailings but send me an email version of RideOn HiddenFields OneTimeAmountCalculation AutorenewAmountCalculation IsIndAutoRenew IsStuSenAutoRenew IsSustainAutoRenew IsJerseyAutoRenew Share this:FacebookTwitterTumblrEmailPrint