Black Diamond Amateur Radio Club

Membership Questionnaire

If you are interested in joining the Black Diamond Amateur Club please complete the for below. Club dues are $15.00 individual and 7.50 for each additional family member living in the same house. Make checks payable to BDARC and mail to:

BDARC

PO Box 472

Beaver, WV. 25823

------------------------------------------------------------------------------------------------------------------------------------------------------

NAME______________________________________________________________

CALL SIGN:_________________________________________________________

ADDRESS:___________________________________________________________

                                                        (Street/P.O. Box)

CITY:_______________________________________________________________

STATE_______________________________________________________________

ZIP CODE:_____________________________________________________________

PHONE NUMBER:_______________________________________________________

E-MAIL ADDRESS:______________________________________________________

LICENSE CLASS:________________________________________________________

BIRTHDAY:_____________________________________________________________

                                                          (Optional)

ARRL MEMBER:_________________________________________________________

                                                            (Yes/No)