Please select the appropriate box: New Member Renewal

First Name: Last Name: Middle Name:

Nick Name: Amateur Call: Expires:

Select License Class: Extra Advanced General Tech plus Tech Novice    E-Mail Address:

Address :      City:

State: Zip+4:       Birthdate :   (Enter as 04/10/65)

Telephone: Home:   Check if Unlisted Work:     Ext.

Occupation:

Are you a Member of the ARRL? Check if Yes    If Yes, give Expiration Date:

Please Select type of Membership: Family : $25.00 Individual : $25.00 Student : $15.00

Additional Family Members:
Name  -   Birthdate   -   Callsign   -   License Class   -   FCC Expires   -   ARRL Expires

I hereby apply for membership in the Alford Memorial RadioClub,Inc. In making this application, I pledge to operate in accordance
with the Club rules and the FCC rules and regulations (Part 97) governing Amateur Radio Service and my equipment.
In addition, I pledge to use only good operating techniques on the Club's repeaters and will not tie up the repeaters
when there are others waiting to use them, or when Simplex communications are possible.

Signature: Date:
(Name and Date entered signify legal digital signature)

Comments to the Membership Chairman: