For a Printer friendly application, please use this link:  Printable Form

Date: ________ Callsign: _________ License Class: ______________

Name: __________________________________________________________

Mail Address: ____________________________________________________

City: ________________________ State: ____ Zip: _________

Telephone Number: Home _________________ (This will be your Autodial number

unless you specify a different number)

Work __________________ Email Address: __________________________

New Member ? ____ Renewal? ____ ARRL Member? ____ (Y/N)

Annual Dues

Individual Membership with one autodial number $36.00

Membership for each immediate family member $12.00**

(Family member is in addition to one paid individual membership)

** Please list below the name, callsign, and license class of each

family member.

Reverse Patch and Mailbox $10.00

Additional autodial numbers $ 5.00 each

Family member: Name _______; Callsign ________; License class ________

Family member: Name _______; Callsign ________; License class ________

Family member: Name _______; Callsign ________; License class ________

Family member: Name _______; Callsign ________; License class ________

Payment

Individual Membership $ _______; Family membership $ _______

Reverse Patch and Mailbox $ ______; Additional Autodial #s ______

Total Payment $ _________

Please mail this application with payment to JARC or bring to a club meeting.