Membership Application for the Elkhorn Valley Amateur Radio Club
P.O. Box 1033
Norfolk, NE 68702-1033
Attn: Club Secretary

FIRST NAME: Middle Initial *: LAST NAME:

ADDRESS: CITY:

STATE:,ZIP:

HOME Phone: Cell Phone *: Work Phone

EMAIL: Web access: Yes No

CALL:             CLASS: EXPIRATION DATE:

ARRL MEMBER: Yes No Life     VE:Yes No ARES:Yes No If Yes enter county/state

Enter Membership type applying for:
     Full ($20.00)
     Family ($30.00) enter family names/calls below
     Student ($10.00, no voting privileges)
     Associate ($15.00, non-ham, no voting privileges)

Enter Family Members names and call signs in box.

Are you interested in being a club officer, on a committee or have any specific interests or comments ?
[Feel free to use the back or attach another piece of paper.]

Signature: Date:Signing this means you are willing to abide by the current Constitution & by-laws.

Print the form and mail it along with your check (made out to EVARC) to the address at the top of the form

Rev date: Nov 22, 2010