Please select the appropriate box: New Member Renewal New Member w/ Autopatch Renewal w/ Autopatch

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 04/11/65)

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)

AUTOPATCH APPLICATION

DO YOU WANT THE AUTOPATCH   Check if Yes   Donation Enclosed: $

Which Repeater do you wish to use for your Autopatch ? 145.450 444.250 Both

In making this Autopatch application, I agree to abide by all FCC rules and regulations, and to abide by any and all club rules, regulations,constitution, and bylaws.
I fully understand that this application and/or autopatch privileges or all autopatch privileges extended may be rescinded or canceled and be made unavailable at
any time with or without notice.

Signature: Date:

Comments to the Membership Chairman: