CALL:_____________ NICK NAME:________________LIC. CLASS:     E     A     G     T+     T     N

NAME:_____________________________________ ADDRESS:_______________________________

CITY:___________________________STATE:_____  ZIP:__________  PHONE:______________________

ARRL MEMBER?    YES_____     NO_____ E-MAIL:________________________________________



Licensed FAMILY MEMBERS, in same household, $5.00 additional fee each

Name:_________________________  Call:__________________ E     A     G     T+     T     N

Name:_________________________ Call:__________________ E     A     G     T+     T     N

INTERESTS:       FOR CLUB USE ONLY:

_____EMERGENCY WORK    PD____________DATE______________
_____TRAFFIC HANDLING    CHK#_________CASH______________
_____VE TEAM      NEW CARD___________________________
_____ELMER      REPEATER CODES REVIEWED_________
_____PUBLIC SERVICE     APPROVED DATE_____________________
_____TECHNICAL COMMITTEE
_____OTHER______________________________  Rec'd by:______________________________

DUES:     Annual dues of $25.00 for FULL member and $5.00 for each family member at the same address, Student Membership is $12.50 are all are payable on or before January 1st.  Memberships not renewed By March 1st will be dropped.

NEW members joining after July 1st shall be ½ the regular yearly cost.

All memberships expire on December 31st.              SIGNATURE:___________________________________

MARCI CLUB MEMBER SPONSOR:_____________________________________     CALL:____________