Membership Application
Name:
Call:
Address:
City:
State:
Zip:
Age:
Birthdate:
Home Phone:
Unlisted
Business Phone:
Extension:
Can we publish your phone number in the club roster ? yes
no
Occupation:
License Class:
FCC License Expires on:
ARRL Member ? yes
no
ARES/RACES Member ? yes
no
Are you a registered VE ? yes
no
Do you have a tone alert system ? yes
no
Are you a registered Skywarn Observer ? yes
no
Are you a MARS Member ? yes
no
if so, which one ?
How long have you been a licensed amateur ?
Are you a member of the QCWA ? yes
no
Do you have a electric generator ? yes
no
If so, what size ?
In the event of an actual emergency, would you object to being called at anytime to assist ? yes
no
Please list any toll call that you might place on the Autopatch
Please indicate the equipment you have:
2 Meter Home
220 Home
440 Home
6 Meter Home
2 Meter Mobile
220 Mobile
440 Mobile
6 Meter Mobile
2 Meter Handheld
220 Handheld
440 Handheld
6 Meter Handheld
HF Rig
Packet
RTTY
ATV
Rain Gauge
Wind Gauge
Barometer
Thermometer
Types of Membership
There are four different types of memberships :
Individual $20.00 per year.
Family membership which is $20.00 for the first family member and $7.50 for each additional family member.
Retired or student membership, $10.00
Associate membership which has no voting privileges is $7.50 per year.
Dues are to be paid to the club treasurer by December 31 for the following year.
Select the membership you desire:
New Member
Renewal
Individual
Family
Retired or Student
Associate
For Family Memberships, please list family members names and calls.
1.
2
3.
4
Members Signature:______________________________________________Date:________________________
Simply fill in the form,
Print out page 1
and mail it along with a check or money order for the proper amount to:
Treasurer
Triple A Amateur Radio Assoc. Inc.
P.O. Box 85
New Brighton, PA 15066
Webmastered by: ke3sv@yahoo.com
© 2008 The Triple A Amateur Radio Association Inc.
