Membership Application for the Elkhorn Valley Amateur Radio Club
P.O. Box 1033 , Norfolk, NE 68702-1033
Attn: Club Secretary

Note: Items marked with * are OPTIONAL all other fields are required.

FIRST NAME: Middle Initial *: LAST NAME:

ADDRESS: CITY:

STATE:,ZIP:

HOME Phone: Cell Phone *: Work Phone

EMAIL: Web access: Yes No

CALL:             CLASS: In training Novice Technician Tech Plus General Advanced Extra EXPIRATION DATE:

ARRL MEMBER: Yes No Life     VE:Yes No ARES:Yes No If Yes

Enter Membership type applying for: [1] Full ($20/YR) [2] Family ($30/YR) (List family members names/ callsigns in box below) [3] Student ($10/YR, NO VOTING PRIVILEGES) [4] Associate ($15/YR, NO VOTING PRIVILEGES)

Enter Family Members names and call signs in box.

Are you interested in being a club officer, on a committee or have any specific interests or comments ?
[Text limited to 3 rows of 80 characters. Feel free to use the back or attach another piece of paper.]

Signature: Date:

Signing this means you are willing to abide by the current Constitution & by-laws.

Print the form and mail it along with your check (made out to EVARC) to the address at the top of the form

Rev date: Dec 30, 2003