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This
form has been suspended to to SPAM. Please contact W4RBH
direct at w4rbh @ wt4ra.org
New AND
renewing members must complete this form.
Using Microsoft
Internet Explorer version 6.0 or newer will give best
results. |
| Bold fields are
required |
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Name: |
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Call
Sign: |
(Use
NA if you are unlicensed) |
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License Class: |
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Email: |
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Street
Address: |
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City, State, and
Zip: |
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Home
Phone: |
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Work Phone: |
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Cell Phone: |
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Let us know about your membership with other
groups. |
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ARRL: |
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AMSAT: |
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MARS: |
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ARES/RACES: |
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10-10: |
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FISTS: |
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QCWA: |
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Other membership: |
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Auto dial phone numbers are for the repeater
speed dial if you wish to use this benefit. |
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Primary auto dial number: |
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Secondary auto dial number: |
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If you are including an additional person for
family membership, complete the next two
fields. |
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Family Member name: |
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Family member call sign: |
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Comments, questions, what interests
you: |
The Email address that you provide must be one provided by
your ISP and not that of an Email reflector or forwarding
service. The Email address you provide will remain private and
will not be published. |
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