Central Florida Cypress Chapter

On-Line Application Form



First Name :                                                     Last Name :                                                       

      Callsign :                                                   Operator Class :                                 

Todays Date :                                      Ten-Ten Number :                       Exp Date :           

Mailing Address :
                                                                                                  

                                                                                                  

                                                                                                  

Email Address :        Publish in club database : Yes     No    
                                                                                                  

Homepage Address :        Publish in club database : Yes     No    
                                                                                                  



Callsign
Name
Date
QTH
10-10#
Cypress #
1                                                                                                                                    
2                                                                                                                                    
3                                                                                                                                    
4                                                                                                                                    
5                                                                                                                                    


All of the above Cypress contacts listed on this application were exchanged over the
air on the amateur 10 Meter Band and not copied or otherwise derived from any listing
or roster. All listed contacts were made directly by me and without the aid of another
station.

Signed:                                            















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© 1999 Central Florida Cypress Chapter