Application form and dues:

Please print out this page, and either mail it to the address below, or bring it to the next meeting.

Name: __________________________________

Call Sign:______________________________

Amateur Class:

Technician      General      Extra

Can you do code?_______________ If so, how fast?____________wpm

Address (mailing):____________________________

City:___________________

State:___________

Zip:_____________

Phone number:________________________

Email:_______________________

What band(s) do you operate?

    >75m   40m   30m   20m   15m    12m    11m(CB)     10m  


   6m    2m    220(1.25m)   440(70cm)    920(33cm)   1300(23cm)

Other (ATV, APRS, EME, etc.)__________________________

What type of membership would you like?

Individual($35)              Family Pack($50)              Donation

Please Make Checks payable to CBRA

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Please Mail Applications to: