First Name :                                                     Last Name :                                                       

      Callsign :                                                   Operator Class :                                 

Todays Date :                                      Ten-Ten Number :                       Exp Date :           

Mailing Address :

                                                                                                  

                                                                                                  

                                                                                                  

Email Address :        Publish in club database : Yes     No    

                                                                                                  

Homepage Address :        Publish in club database : Yes     No    

                                                                                                  

	Callsign	Name	Date	QTH	10-10 #	SC #	Pts.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

                  Please use a seperate piece of paper if more space is required

All of the above Samuel Clemens contacts listed on this application were exchanged over
the air on the amateur 10 Meter Band and not copied or otherwise derived from any listing
or roster. All listed contacts were made directly by me and without the aid of another
station.

Signed:                                               






Mail your completed application with applicable fees & postage to:

Robert F. Bailey WA2YZM
1365 Kettledrum Trail
Enterprise, Florida 32725-2436

© 2000 Samuel Clemens Chapter