W7MVR - Amateur Repeater

View of the site looking north.

W7MVR - Repeater Club, application

CLUB APPLICATION

__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, ANNUALLY 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 _____________