Membership Application

CHARLES COUNTY AMATEUR RADIO CLUB, INC.

(K3SMD)

Post Office Box 169, La Plata, MD 20646-0169

Membership Application

Please print clearly

Name __________________________ Call Sign ___________ Class _____ ARRL Member? _____

Birthday ___________________ License Expiration Date __________________

* * * * * * * * * * * * * * * * * * * * * *

Spouse ________________________ Call Sign ___________ Class _____ ARRL Member? _____

Birthday ___________________ License Expiration Date __________________

* * * * * * * * * * * * * * * * * * * * * *

Child _________________________ Call Sign ___________ Class _____ ARRL Member? _____

Birthday ___________________ License Expiration Date __________________

* * * * * * * * * * * * * * * * * * * * * *

Child _________________________ Call Sign ___________ Class _____ ARRL Member? _____

Birthday ___________________ License Expiration Date __________________

Mailing Address:

(Street) ______________________________________________________________________

 

(City) _________________________________, (State) _____________, (Zip) ___________

Phone (H) __________________________ (W) ______________________________

E-Mail _____________________________ Fax ______________________________

If you or any member of your family has any special skills that could assist the club, or any suggestions for club activities in which you would like to participate, please give a brief description:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

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Annual dues are $24.00 for a single membership and $5.00 for additional members of the same household. Dues are due on the first day of January. Dues for first time members who join during the calendar year will be prorated by month. All checks should be made payable to the Charles County Amateur Radio Club, Inc.

If there is any information above that you would not want published in the club membership roster, please indicate below:

____________________________________________________________________________________

____________________________________________________________________________________

Club membership includes participation in the club’s A.R.E.S./R.A.C.E.S program.

I hereby agree to abide by the By-Laws of the Charles County Amateur Radio Club, Inc.

 

(Signed)______________________________________ (Date)__________________________

Rev.04/03