Chapter #126
Member number

_____________
(for official use only)

I, __________________________________________________CALL_____________
hereby apply for MEMBERSHIP in the Piedmont NC Chapter #126.  I am 
eligible, since I am presently a member of the Quarter Century 
Wireless Association, Inc.

Mailing Address________________________________________________________

               ________________________________________________________

Class Of License________________

Date of First License______________ First Call____________

Present Occupation_____________________________________________________

Major Life Work________________________________________________________

_______________________________________________________________________

Hobbies, other than radio______________________________________________

_______________________________________________________________________

Miscellaneous__________________________________________________________

Telephone (_____)___________E-mail_____________________________________

QCWA National Nr._________

Birthday: Month _____ Day _____

Signed___________________________________________ Date_________________


ANNUAL DUES are $7.00. Life membership is also available; lifetime dues are $70.00.
Send application and dues to :

Sue Meyer Parks
PO Box 1435
Graham, NC 27253
e-mail: w2ghksue at gmail.com