CENTRAL CONNECTICUT AMATEUR RADIO CLUB

                   APPLICATION FOR GENERAL MEMBERSHIP    

               Name: ______________________________________________________________

               Call:________________Class:_______________

               Address: ________________________City,________________State___Zip________

               Telephone: _____________________ E-mail:______________________

                       Equipment currently owned:      2 meter,   220,    440,       Packet,       HF

                                                               (circle all that apply)      

               Amateur Radio Interests:        Public Service    Emergency Communications    Field Day,
                                             Technical            Social Activities     (circle all that apply)

        Do you currently hold a valid amateur radio license issued by the FCC? (circle one)
                                                                  Yes         No
                   

           Signature: _________________________________  Date: ____________

Yearly Membership Fee: $10 

Please print, fill out form and send along with membership fee to :  

Central Connecticut A.R.C.

P.O.Box 471

Plainville, Ct  06062