| 222.880 / 224.480 | 147.415 / 146.415 | 442.875 / 447.875 |
Please print this form, fill in the requested information, and send the form, together with a check for the appropriate amount, to:
WA2JSB
27 Lincoln Avenue
West Orange, NJ 07052
Please make checks payable to the W2QR Repeater System.
| Name: | _________________________________________ | Call: __________ | |
| Address: | _________________________________________ | Class: _________ | |
| _________________________________________ | Exp. Date: ______ | ||
| Phone (Home): | ____________ | (Business): ____________ | |
| Publish Home # in Roster | ___ Yes ___ No |
||
| Email Address: | _________________________________________ | ||
| Other Amateur Radio Club Affiliations: _______________________________________________________ |
| ____________________________________________________________________________________ |
| Are you able to participate in public service events communications? | ___ Yes ___ No |
| What VHF-UHF equipment do you have? | ___ 2M ___ 220 MHz ___ 450 MHz |
| Please enclose a check for $24 for both repeaters | |
| For Repeater Database Use Only: | |
| Date Received: _____________ | |
| Dues Cash _____ Check _____ # ______ | |
| Date info entered into system: ____________ |