Kansas City DX Club

Membership Application

Please print this form, complete it, and mail it, together with a check in the amount of $15.00 (annual dues) to Rick Barnett, KB0U - P.O. Box 4798, Overland Park, Kansas, 66204

Date:________________

Name:_________________________________ Callsign:____________

Street Address:________________________________

City:__________________ State:_______ Zip:_______

Home Phone:_____________Work Phone:__________

License Class:____________

Email Address:_______________

Website URL:_________________