CLUB APPLICATION FOR 2012
__RENEWAL __CHANGE OF INFORMATION __NEW APPLICATION __FAMILY
NAME: ___________________________________________________________
(PLEASE PRINT) LAST FIRST MI
ADDRESS: _____________________________________________________________________
PO BOX CITY STATE ZIP
CALLSIGN _________________CLASS _____________EXP ______________
HOMEPHONE: ________________WORKPHONE:_____________________
CELL: _________________________EMAIL: _________________________
MEMBER ARRL_____ RACES/ARES______VE ARRL _____ W5YI _______
MEMBERSHIP DUES RUN FROM: 01 FEBRUARY THRU 31 JANUARY 2012 AT $25.00/YEAR
ADDITIONAL MEMBERS OF SAME HOUSEHOLD ADDITIONAL $5.00/YR
PLEASE SUBMIT ADDITIONAL FORM FOR EACH ADDITIONAL MEMBER.
MAKE CHECKS PAYABLE TO "MOAPA VALLEY AMATEUR CLUB"
SEND TO MOAPA VALLEY AMATEUR CLUB, PO BOX 664, LOGANDALE, NEVADA, 89021
SIGNATURE _____________________________ DATE _____________
