I, the undersigned, hereby apply for admission to membership of the Brisbane Amateur Radio Club. If accepted for membership, I agree to abide by the Constitution and By-Laws of the Club.

Name: …………………………………………………………………………………….

Address: ………………………………………………………………………………….

Post Code: ………………….. Home Telephone No.: …………………………….

Occupation: ……………………………………. Amateur Callsign:………………

If you wish any of the following to be omitted from published Membership lists, please tick the ones to be omitted.

Address [ ] Phone No. [ ]

Signed: ………………………………..

Date: ………………………………..

COMMITTEE USE ONLY

Proposer: …………………………………………… M'ship No.: …………………….

Seconder: ………………………………………….. M'ship No.: …………………….

Payment Received: $……………………… Receipt No.: ………………………..

Date Accepted/Rejected ………………… M'ship No. Issued: …………………

President: ………………………………….. Secretary: ………………………………