Samuel Clemens Chapter

Electronic Application Form



This form is to be used for New Samuel Clemens applications only!

To print an application sheet on your local printer click here!


Name: First> Last>
Address >
City > State >
Country > Zip >

Callsign > 10-10 # > Expiration Date - MM/YY>


Please enter ALL application information!
Incomplete forms can not be processed!

Email > Publish in chapter database? YesNo
Your website > Publish in chapter database? YesNo


C
HC, L, HM
FS, FC, FP, DX
All Others
10 pts
5 pts
3 pts
1 pt

Please use the following format to enter stations worked:
Callsign, Op name, 10-10 #, date worked (mm/dd/yy), SC number, points
DO NOT PRESS ENTER!
Use the arrow keys to move!


By clicking the "Submit" button on this form, I certify that 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.

For your records, click on your browsers print button before you submit your application.


   


or, you may mail your completed application with applicable fees & postage to the chapter Certificate Manager:

Bob Bailey WA2YZM
1365 Kettledrum Trail
Enterprise, Florida 32725-2436



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© 2000 Samuel Clemens Chapter