NEW
C/O James Donohue
Membership Application
Name (Last, First) _______________________________________________
Nickname or Name you prefer to be called ____________________________
Callsign _____________________ License Class: T__ T+__ G __ A __ E __
ARRL Member Yes ____ No ____
Birth Date: Month ________ Day ______ Year ________
Address: _______________________________________________________
Home Phone: _____________________ Work Phone: __________________
Email Address: _____________________ Cell Phone: ___________________
Occupation: _____________________________________________________
Equipment Make and Model:
HF : _________________________________________
VHF: ________________________________________
Amateur Radio Interests: (Check all which applies)
HF ____ CW ____ SSB ____ RTTY ____ SSTV ____ FSTV ____ QRP _____
VHF ____ PACKET ____ PSK31 ____ FM ____ DV _____
Other Ham Interests: _______________________________________________
________________________________________________________________
Other Hobbies: ____________________________________________________
_________________________________________________________________
What can you do for the Club to promote and help it grow? _________________
_________________________________________________________________
How can the club Help you? _________________________________________
________________________________________________________________
Additional Remarks: _______________________________________________
_________________________________________________________________
Please enclose the Annual Dues when submitting this application.
Signature: ____________________________________ Date: ________________
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For Club use Only: ____ MM/ _______DD/ _______YY/ Initial: _________
Application Received: _______ MM / _______DD/ ________YEAR
Read into Minutes: ________MM / ________DD/ _________YEAR
President
Vice President
Sec/Tres:
Trustee
Voted in?
Denied?
Dues Received: Y ____ N _____ Date ___/ ____/ ____
Amount: ________ Cash: _______ Check # ________
Dues Returned if Denied Y ____ N ____ Date: _____/ ______/ ______
Remarks: _______________________________________________________
_______________________________________________________________
Individual membership
is $10.00 per year.
Family of two or more
who live at the same residence is $15.00 per year.
Please make checks
payable to: NK4DS