NAME:__________________________________________________

CALL:_____________ LICENSE CLASS:(circle)  N  T  T+  G  A  E

ADDRESS:_______________________________________________

CITY:___________________________STATE:_____ZIP:___________

E-MAIL: _________________________ BIRTHDATE:____/_____/____

HOME PHONE: (_____)__________WORK PHONE:(_____)___________

I belong to (circle): ARRL  RACES  ARES  MARS  NTS  Other clubs:________

Bands used (circle):160m  75/80m  40m  30m  20m  17m  15m  10m  6m 2m  70cm
Modes used (circle):  SSB  FM  CW  Packet  RTTY  SSTV ATV  Amtor/Pactor

Mobile equipment:____________________________________________

Fixed station:________________________________________________

Check the appropriate category/categories:
_____FULL MEMBER $25 (Licensed Alger County Resident)
_____SUPPORTER MEMBER $20 (Licensed Non-Resident)
_____JUNIOR SUPPORTER MEMBER $10 (Opened to anyone)
_____FAMILY MEMBER $10.00  (must be licensed and reside at same address)

______________________________ Name, Call, License, etc.