NAME: __________________________________________________ Member of The ARRL?       Y        N            $20.00 Full Member
ADDRESS: _________________________________                                                                                                                    $10.00   Associate Member   
CITY: __________________    STATE: _________________   ZIP: ____________                                                           $5.00 Family Member
PHONE:    ( ___ ) -_______________
Call Sign (If none, write 'NONE'):___________________(Class)_______________     
Name of any Family Members: _____________________________Callsigns of any Family Members:____________(Class)__________  
Referred to club by?   (i.e.: net, friend, webpage.... etc): ________________________
Brief description of radio gear you own and your primary interests in Ham Radio.
*How many years have you been licensed? _________________________________  
*Previous callsigns held? _____________________________________________
Would you be willing to 'ELMER' a fellow ham?   Y         N 
By filling out and signing this application, the applicant agrees that it will be reviewed by the club**, and whomever the club deems necessary to confer with. Upon completion of the review of this application, the club will make the final decision as to the admission of the applicant into the club. The applicant agrees further that he (or she) will abide by the rules and by-laws set forth by the founders of the club, and as amended during the course of the club's existence upon his (or her) acceptance into the club.
The associate membership is for all new members and is for a period of 90 days. During the 90 days the new member will be evaluated on repeater skills and compliance with part 97 of the FCC rules before being allowed a full membership. ALL new full memberships must be approved by a majority of club members in good standing. Not withstanding, the board shall reserve the right to offer full membership to the associate member who completes the probationary period. A breach of the rules by the probationary member will mean that he/she shall forfeit the right to associate or full membership for the period of one year at which time he/she may reapply. The associate member shall have no voting rights. During the period of associate membership the dues will be TEN DOLLARS. Upon successful completion of probationary period and upon being voted to a full membership the balance of all applicable fees and dues shall be paid. If probation is not successfully completed the associate membership fee of ten dollars will be forfeited by the Individual.
I Have Read and Understand the above Terms and agree to be bound by these rules

Signed   ___________________________      Date _____________

Mail Application To: Mid-Island ARC    P.O. 377   Mt. Sinai, NY 11766           

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Reviewed By _________________     Position __________________    Date _____________

Do not write in this box