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ARKAN Newsletter -- Page Nine

Amateur Radio Klub of the Arkansas Northwest Membership Application

Personal Information:

___

New Application

___

Yearly Membership Renewal Application

Applicants Name: ______________________________________________ Age:___________ ARRL Member: YES NO Spouse'sName:_______________________________________________ Other household members holding licenses: Name:________________________________________________________ Name:________________________________________________________

Callsign: ______________________ ARES Member: YES NO Callsign:_______________________

Callsign:_______________________ Callsign:_______________________

Class:

Class:

Class: Class:

______________

______________

______________ ______________

StreetAddress:

_____________________________________________________________________________________________

City:_____________________________________________________________________________

State:

_________

Zip Code:

______________

Home Phone:

Work Phone:

Cell Phone:

___________________________

____________________________

__________________________________

E m a i l A d d r e s s : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ P e r s o n a l W e b S i t e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Membershipinotherorganizations:__________________________________________________________________________________________________

Interests: VHF/UHF Y / N

APRS Y / N

Packet Y / N

Satellite Y / N ATV Y / N Spe. Events Y / N ARES Y / N SKYWARN Y / N

HF Y / N

Phone Y / N

CW Y / N

Digital Modes: RTTY Y / N

PSK31 Y / N

Contesting Y / N

OtherNon-AmateurInterests:__________________________________________________________________________________________________________

Please attach a copy of amateur radio license(s) for all those applying for membership. Dues are $20.00 for first club member and $5.00 for each additional family member.

I acknowledge that I will follow all FCC rules and regulations as well as the by-laws of the Amateur Radio Klub of the Arkansas Northwest. Any infraction will result in immediate termination of membership in the club.

ApplicantSignature

_____________________________________________________________________________

Date

______________________________

Sponsored by (Print) ___________________________________ Signature_______________________________________ Board of Directors Approval

Date

________________________

________________________________ ________________________________ License attached: Y/N

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Dues Payment Attached: Y/N

________________________________ ________________________________ Amount of Payment: $_____________

RECEIPT FOR ARKAN DUES

Date:

__________________________

Receivedfrom: Amount: For: Callsign:_________________________________ _____________________________________________________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

ReceivedBy:_________________________________________________________

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