PARK COUNTY RADIO CLUB, Inc.
MEMBERSHIP  APPLICATION

NAME: __________________________________________ DATE: ___________

CALL SIGN: ______________ BIRTHDAY (month and day only) ______________

ADDRESS: ____________________________________   COUNTY: ___________

CITY, STATE, ZIP: ________________________________________________________

PHONE: ___________________  E-MAIL: _______________________________

NOTE:  If you are a summer or otherwise part time resident of  the above address please 
give an address to which we can send the Newsletter when you are away.  Please also 
give e-mail address if different from above. __________________________________________________________________________

DUES:  Annual dues are $20 per member, with an additional $10 to include as full members all licensed family members living under the same roof. Donations over and above these amounts are always acceptable!!!   We have been determined to be a tax exempt non-profit organization under IRS rules.  

PLEASE  INDICATE   ARRL membership:   YES________  NO ________

Would you be willing to serve on a committee or as a club officer in the future?

What are your special interests in Ham Radio?

Operating practices:  CW ____       ;  HF BANDS _______________ UHF/VHF ________

Do you have an area of expertise you would be willing to share with the club at a future meeting? _______   On what subject? _________________________________________

Are you interested in being part of the Amateur Radio Emergency Service (ARES) team? 
___

Would you prefer the paper or electronic edition of the newsletter QUA?  Paper __; 
Elect. __

Names and callsigns of other family members included with your dues:

Please return this form and your check made out to the Park County Radio Club, Inc., 
or simply PCRC to            E. R. Bova - WØWPD, PCRC Secretary
                                   360 E. Pinon Road  -- Bailey, Co – 80421  

(Rev 1/9/05)                                              73,  PCRC Sec’t.