Application for S.S.A.R.C. Membership

P.O.Box 701 Grandview, MO 64030

Amateur Call:_____________________

Name:_______________________________________________________
                 Last                                       First                       Mi                                Preferred Name

Address:_____________________________________________________

____________________________________________________________
  City                                                       State                                                               Zipcode

Phone: (     ) ____________________ E-MAIL______________________
License Class:___________________Expiration Date: _______________

       [  ]  Please mark this box if you have amateur operators in your immediate family
             who live in your household that would not like voting privileges.
                                  There is no additional charge for this membership.

Please list family members below:

Are you an ARRL member? _______ If yes, are you a lifetime member? ________

I hold a valid Amateur Radio Operators License. I agree to follow the rules and protocols of the
S.S.A.R.C. and the Federal Communications Commision.

X ____________________________________________ Date __________________

Dues are $18.00 annually (Prorated for new members only at the rate of $1.50 per month).