APPLICATION

TO JOIN THE

NUTMEG CHAPTER 149 OF THE

QUARTER CENTURY WIRELESS ASSOCIATION, INC

NAME________________________________CALL____________________________DATE_____________________________

ADDRESS_____________________________________________________________

                  ______________________________________________________________

                 _______________________________________________________________

DAY TIME TELEPHONE NUMBER____________________________EMAIL ADDRESS________________________________

Requirements:   You must have been licensed for more than 25 years. You must be a member in good standing of the

Quarter Century Wireless Association, Inc.

MEMBER OF QCWA, INC?____YES____NO

DATE FIRST LICENSED________________________________________

IS THIS APPLICATION ALSO FOR CLOSE RELATIVE OR SPOUSE LIVING WITH YOU?  IF SO:

NAME_____________________________CALL_______________________________FIRST LICENSED_________________