STARVED ROCK RADIO CLUB INC.

MEMBERSHIP REGISTRATION FORM

ED 3/2009

COMPLETE FORM AND MAIL TO:

SRRC

PO BOX 198

LEONORE IL 61332

Enclose payment as follows:

1 calendar year - $24.00

Add all family members - $5.00

Part year dues prorated.

NOTE * means REQUIRED FIELD. Form will be rejected if this information is not shown.

*APPLICATION TYPE ___New Member ___Renewal ___Previous Member

*NAME ____________________________________CALL SIGN_____________

*ADDRESS_________________________________DATE OF BIRTH________

*CITY, STATE, ZIP __________________________COUNTY_______________

E-MAIL ADDRESS___________________________TELEPHONE____________

*ARRL MEMBER? (Y/N)________LICENSE CLASS_______________________

*CLUB NEWSLETTER “STATIC” via e-mail or U.S. Mail? EMAIL___U.S.___

EMAIL FOR NEWSLETTER (if different)________________________________

List other HAM family members living at same address:

NOTICE: Dues for each member must accompany this form. Funds received by the Club without this form will be considered donations. Complete rules of the Club can be found at www.qsl.net/w9mks Printed copy of rules is available from Secretary.

By signing I agree to abide by these rules

*SIGNED_________________________________________DATE_____________

CLUB USE: Rec’d by______Date:_________Payment:_____________

Recorded by Treasurer_______________Secretary_______________