Call sign: Class of License:

ARRL Member (Yes Or No?): ARRL Experation Date?:

Address:

City: State: Zip Code:

Your Email Address:

Home Phone Include Area Code:

Do you want your home phone number included in the Club roster (Y/N)?

Work Phone Include Area Code:

Do you want your Work phone number included in the Club roster (Y/N)?

Do you want your Home phone number included in the Club Web page (Y/N)?

Do you want your Work phone number included in the Club Web page (Y/N)?

Do you want your Email addreess in the Club Roster (Y/N)?

Do you want your Email addreess in the Club Web page (Y/N)?

____________________________________________________________________ Membership is from Jan.1st to Jan 1st and FREE! for the first year, to New members.

Pick One/ Full or Associate $18.00 Student $12.00 Family Membership $24.00

Call Signs of all family members