Member Information/Application Form
Douglas County
Amateur Radio Club
This form is to be used both for new member applications and for current members to update their personal information at dues renewal time.
Name: _________________________________________
Name callsign issued in, if different: ________________________________________
Callsign: _________________ License Class: ___________________________
Mailing Address:
_____________________________________________________________________
(street address, P.O. Box, etc. Include apt./lot no., etc.)
City: ________________________ State: _______________ Zip: _________________
Membership Dues per calendar year are:
Regular Membership $25.00
Family Membership $30.00
Senior (65+) $20.00
Newsletter Only $15.00
New members may join at any time. The treasurer must receive renewal dues no later than March 1 each year to maintain membership.
Please circle your category of membership, sign and date below and return to the treasurer with your dues.
_____________________________________ ___________________________
Signature Date
Only the above information is required for club membership records. However, the following information will be helpful in responding to requests from the public for Club assistance and in providing programs, newsletter articles, etc. which are of interest to the membership. Participation is strictly voluntary.
Optional Information:
Home Phone: _______________________ Work Phone: ____________________ x _________ (only if okay to contact you at work)
Email Address: _______________________________________ Packet Address: _______________________________________
Birthday (year optional): _____________________ Years Licensed: _____________________________
Previous Callsigns (if any): _____________________________________________
ARRL Member? yes ____ no _____ RACES/ACT Member? yes _____ no ______
MARS Member? yes ____ no _____ Branch ________________________
What are your major interests in Amateur Radio?
What kinds of activities do you like best (participating in Field Day, fox hunts, public service events, etc.)?
What kinds of club programs are of most interest to you?
Would you be willing to present a program to the club? If so, on what topic(s)?
If you are not already an Extra Class, do you intent to upgrade further?
If so, what would be of greatest help to you in doing so?
Would you be willing to serve as a Volunteer Examiner or otherwise assist with the license classes the club offers?
Would you be willing to open up your station for visits by club members (with proper pre-arrangements and in numbers suitable for your situation)?
Do you know anyone who might be interested in joining the club? (Please provide name and address/telephone number)
What other hobbies and interests do you enjoy?
What is the name of your spouse? Children?
Are any of them licensed/interested in Amateur Radio?
Please complete the following chart regarding your equipment/privileges/capabilities. Put a check mark or X in each box that applies. Add any other relevant information below the chart.
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BAND |
CW |
SSB |
FM |
PACKET |
OTHER DIGITAL MODES |
ATV |
SAT |
MOB |
PORT |
BATT |
GEN. |
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160m |
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80m |
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40m |
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20m |
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15m |
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10m |
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6m |
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2m |
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1.25m |
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70cm |
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other |
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For Club Use Only
Application voted on and _______ accepted _________ denied.
Dues paid for current year? _____ yes ______ no