THE ANCIENT MODULATORS CLUB
"Dedicated to the restoration and preservation of AM Radio"
Club Call Sign:  KØAMC
Web: http://www.qsl.net/k0amc
E-Mail: k0amc@qsl.net

MEMBERSHIP APPLICATION

Please print this form, fill in the information with ink, sign and date, mail it,
along with a check for $20.00 made out to: "The Ancient Modulators Club".
Rich is also accepting Pay-Pal payments, but if so add a 3% Pay-Pal fee.
Any Questions Call:  Rich 636-366-7272

MAIL TO: or Pay-Pay to richard@k0rww.com
Richard Fitzmaurice  KØRWW
Club Secretary-Treasurer
15Ø Brook Hill Lane
Troy, MO 63379-3465

NAME:___________________________________________CALL SIGN:______________________

STREET ADDRESS:_________________________________________________________________

CITY,  STATE,  AND ZIP:_________________________________________________________

HOME PHONE:__________________________ CELL PHONE:_______________________________

EMAIL ADDRESS:__________________________________________________________________

DATE FIRST LICENSED:_____________________OK TO LIST PHONE NO ON WEB SITE?_______

LIST OLD CALL SIGNS & CLASS_____________________________________________________

What Amateur Activities Do You Like The Most?, and/or your personal web site URL

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SIGNATURE OF APPLICANT, AND APPLICATION DATE BELOW:

__________________________________________________________Date:_________________
NOTE: Not required, but If you would like to write a short Bio, about your radio
interests, and also we would like to post a photo or 2, perferably of you at
your station, on our web site. Please Email to Paul  k0rwu@qsl.net
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THIS AREA TO BE FILLED IN BY CLUB OFFICERS:

SIGNATURE OF SPONSOR:____________________________________Date:_________________

INITIATION FEE PAID: TREASURER:__________________________Date:_________________

MEMBER APPROVED: CLUB OFFICER:___________________________Date:_________________

DATE MEMBERSHIP ENDED:_________________REASON:_________________________________