Year 2011 Application for Membership
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.
Juneau Amateur Radio Club, P.O. Box 35484, Juneau, AK 99803-5484