QUARTER CENTURY WIRELESS WOMEN - CHAPTER #120 QCWA
                  Membership Application and Info Sheet


   I hereby apply for Membership in the Quarter Century Wireless Women
   Chapter of the Quarter Century Wireless Association - a chapter
   dedicated to encouraging qualified women amateurs to actively
   participate in QCWA activities.

   I agree to support the purposes of the Chapter and abide by its By-laws.

   Name _____________________________________ Call___________________________

   Address __________________________________________________________________ 

   City ___________________________________ State ___  Zip __________-_______
   
   Telephone Number ( ___ ) ____ - _____ E-mail _____________________________

   QCWA Membership Expiration Date _________ License Expiration Date ________

   QCWA # __________________         Signed _________________________________

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   * We would like the following information for our files.                 *
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   * Birthday - Month ___ Day ___   Wedding Anniversary - Month ___ Day ___ *
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   * OM (XYL) - Name _____________ Call (if licensed) _____________________ *
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   *                  Birthday - Month ___ Day ___                          *
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   * Other Clubs __________________________________________________________ *
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   * ______________________________________________________________________ *
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   * Hobbies ______________________________________________________________ *
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   * ______________________________________________________________________ *
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        ANNUAL DUES $5.00             Send to:
                                        Ann Nutter - VE3HAI
                                        1 Clearside Place
                                        Toronto, ON M9C 2G5 Canada

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