Hocking Valley Amateur Radio Club
                                       Joe Berman Memorial Fund
                                           Application Form

Name (print):__________________________________________  Call Sign:_________________

Date:___________________               Check Category applying for and fill out only that section
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 (  )Category A – New Licensee (also attach HVARC Membership Form to this Application)

License Grant Date:____________________

I certify that I am a New Amateur Radio Licensee, or have not held a valid Amateur Radio License for
at least Five (5) years prior to the Grant Date above, have not had a license revocation or
suspension by the FCC, and am a permanent resident of Athens, Hocking, Perry, Pickaway, Ross,
or Vinton County, and am applying for membership in the HVARC.
(Sign Below)
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 (  ) Category A – Reimbursement of FCC Application Fee

Activities Completed for Reimbursement:
Date               Activity

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

I certify that I completed the above activities as required, and that I am a Full Member of the HVARC.
(Sign Below)
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 (  ) Category B - License Class Upgrade by Existing Club Member 

Grant Date of License Class Upgrade ______________________

I certify that I am a current Full Member of the HVARC, and have successfully Upgraded my License Class.

>>>>>Sign Here (All Categories)________________________________________