THE ANCIENT MODULATORS CLUB
"Dedicated to the restoration and preservation of AM Radio"
Club Call Sign:  KØAMC
Web: http://www.qsl.net/k0amc
E-Mail: k0amc@qsl.net

MEMBERSHIP APPLICATION 7/30/2019 

Please fill in the information, sign, date, and mail it
along with a check for $25.00 payable to: "The Ancient Modulators Club".
Payment by PayPal is also accepted, but if used, add $1.00 for Pay-Pal fee. 
PayPal to richard@k0rww.com
Any Questions, 8am – 8pm, Call:  Richard 636-875-2242

MAIL TO:
Richard Fitzmaurice  KØRWW
Club Secretary-Treasurer
150 Brook Hill Ln
Troy, MO 63379-3465

NAME:___________________________________________CALL SIGN:______________________

STREET ADDRESS:_________________________________________________________________

CITY,  STATE,  AND ZIP:_________________________________________________________

HOME PHONE:__________________________ CELL PHONE:_______________________________

EMAIL ADDRESS:__________________________________________________________________

DATE FIRST LICENSED:_____________________OK TO LIST PHONE NO ON WEB SITE?_______

LIST OLD CALL SIGNS & CLASS_____________________________________________________

What Amateur Activities Do You Like? Do you have a personal website URL?

________________________________________________________________________________
QRZ.com
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SIGNATURE OF APPLICANT, AND APPLICATION DATE BELOW:

__________________________________________________________Date:_________________
NOTE: Not required, but If you would like to write a short Bio, about your radio
interests, and we would like to post a photo or 2, preferably of you at
your station, on our web site. Please Email photos to Don kd0oqv@qsl.net
_______________________________________________________________________________
THIS AREA TO BE FILLED IN BY CLUB OFFICERS:

SIGNATURE OF SPONSOR:____________________________________Date:_________________

INITIATION FEE PAID: TREASURER:__________________________Date:_________________

MEMBER APPROVED: CLUB OFFICER:___________________________Date:_________________

DATE MEMBERSHIP ENDED:_________________REASON:_________________________________