Current Call Sign ________________________________________________________________________________________________________________

Date _____________________________________________________________________________________________________________________________

Previous Call Sign (if applicable)________________________________________________________________________________________________

Name_____________________________________________________________________________________________________________________________

Birthday ___________________________________________________________________________________________________________________________________

Spouse___________________________________________________________________________________________________________________________

Address__________________________________________________________________________________________________________________________

City_______________________________________________________________________________________________________________________________

State________________ Zip______________

Telephone (_____)___________________  Cell (_____) ______________________

Email Address__________________________________________________________________________________________________________________________

License Class and date Earned :

Technician ___________________________________________________________________________________________________________________________________

General  _________________________________________________________________________________________________________________________

Advanced  _______________________________________________________________________________________________________________________

Extra ____________________________________________________________________________________________________________________________

Are you a member of any of these organizations?/Plan to join?

A.R.E.S. ____________  ARRL ___________________

M.A.R.S. ____________  VE _____________________

Would you be willing to serve as a Club officer in the future? ___________________________________________________________________________________________________________________________________

What type of Club activities would you be willing to help with?

___________________________________________________________________________________________________________________________________

Please list what parts of Amateur Radio is of interest to you.

___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

When completed mail to the club or bring to a meeting with a check for $20 (annual dues).