Chestnut Ridge Amateur Radio Club, Inc.

Application for Membership

NAME: ____________________________________________ CALL: _____________________

ADDRESS: _____________________________________________ CLASS: N , T , T+ , G , A , E

CITY: _________________________________ STATE: ________ ZIP: ___________ - ________

HOME PHONE: __________________________ WORK PHONE:__________________________

CELL PHONE: ___________________________ PAGER NUMBER: _______________________

PAGING SERVICE (Page Net, USA Mobile etc..)________________________________________

TYPE OF PAGER: ___ ALPHANUMERIC, ___ NUMERIC. E-MAIL ADDRESS_____________

If you operate Packet, what is your home BBS: ________________ Personal MBX_____________

OCCUPATION: __________________________________________________________________

SPECIAL TRAINING:______________________________________________________________

AFFILIATIONS: ___ MARS ___ ARES ___SKYWARN___ SATURN ___NTS ___ ARRL

OTHERS: ________________________________________________________________________

COMMENTS: ____________________________________________________________________

_________________________________________________________________________________

SPONSORING MEMBER: _________________________________ DATE: __________________

Please accept my application for membership into the Chestnut Ridge ARC, Inc. I hereby agree to abide by the by-laws of the club and conduct myself, at all times, by the high standards set forth by the Amateur Radio Service. I have enclosed my application fee of $15.00 for a single or $25.00 for a family membership. I also understand that I will be notified by the secretary as to the outcome of my application.

APPLICANTS SIGNATURE: _______________________________ DATE: ________________

Please mail this application with the appropriate dues to:

Chestnut Ridge Amateur Radio Club, Inc.

P.O. Box 175

Loyalhanna, PA 15661-0175

Make Check(s) payable to CRARC