Membership Application
            Name:       Call:
            City: State:   Zip:       Age:   Birthdate:
            Home Phone:     Unlisted             Business Phone:       Extension:
            Can we publish your phone number in the club roster ?       yesno
            License Class:     FCC License Expires on:
            ARRL Member ? yesno      ARES/RACES Member ? yesno       Are you a registered VE ? yesno
            Do you have a tone alert system ?   yesno         Are you a registered Skywarn Observer ?   yesno
            Are you a MARS Member ?   yesno         if so, which one ?
            How long have you been a licensed amateur ?         Are you a member of the QCWA ? yesno
            Do you have a electric generator ? yesno       If so, what size ?
            In the event of an actual emergency, would you object to being called at anytime to assist ? yesno
            Please list any toll call that you might place on the Autopatch

Please indicate the equipment you have:
2 Meter Home 220 Home 440 Home 6 Meter Home
2 Meter Mobile 220 Mobile 440 Mobile 6 Meter Mobile
2 Meter Handheld 220 Handheld 440 Handheld 6 Meter Handheld
HF Rig Packet RTTY ATV
Rain Gauge Wind Gauge Barometer Thermometer

Types of Membership
There are four different types of memberships :
Individual $20.00 per year.
Family membership which is $20.00 for the first family member and $7.50 for each additional family member.
Retired or student membership, $10.00
Associate membership which has no voting privileges is $7.50 per year.
Dues are to be paid to the club treasurer by December 31 for the following year.

Select the membership you desire:
New Member        Renewal        Individual        Family        Retired or Student        Associate
For Family Memberships, please list family members names and calls.
1.                 2
3.                 4

        Members Signature:______________________________________________Date:________________________

Simply fill in the form,
Print out page 1
and mail it along with a check or money order for the proper amount to:
Triple A Amateur Radio Assoc. Inc.
3913 40 th St
New Brighton Pa  15066

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2014 The Triple A Amateur Radio Association Inc.