____New ____Renewal
Full Name:____________________________ Call Sign:_________________
Name used on the air:_________________
Address:______________________________ Phone ( )___________
______________________________________
___________________ Zip:____________
E-Mail address:_________________________________________
License Class
___ Novice ___ Technician
___ General ___Extra
Membership Category
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Membership is $24 a year and $6 a year for each additional member in
your house. Or you may choose to pay on a monthly basis at $2 a month.
$____________
Signature________________________ Date_______________________
________________________________________________________________________