Print out this page on your printer and follow the instructions on the application. Please allow 4-6 weeks for your membership information to arrive.

UTICA SHELBY EMERGENCY COMMUNICATION ASSOCIATION,Inc.

USECA Application

***Membership Form***

Date________________________New________Renewal________________

Call:________________________Class_______________Auto Patch: ____________

Name_______________________________________________________________________

Address:_____________________________________________________________________

City:___________________________________________State:_________Zip:_______

Telephone Number_________________________________Print in Roster ____Yes_____No

Birth Date________________________________________Copy of Current License for USECA File______

Member ARRL____Yes____No ******* RACES____Yes____No

____________________________________________________________________________________

FOR FAMILY MEMBERS ONLY:

#1 Call_______________________Class_________________

Name________________________Birth Date______________

#2Call_______________________Class___________________

Name_______________________Birth Date________________

Member #1! ARRL____Yes____No --------- MEMBER #2: ARRL____Yes____No

RACES____Yes____No --------- RACES:____Yes____No

________________________________________________________________________

Annual Membership Dues (Includes Newsletter) Regular: $20----Family: $30

(Auto Patch:$35 One Time Fee) + Annual Dues

Applications can be given to the Membership Secretary at monthly meetings or mailed.

PLEASE MAKE CHECKS PAYABLE TO: USECA

Please mail this form and your check to:

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USECA NETS