BRANTFORD AMATEUR RADIO CLUB

VE3BA logo               MEMBERSHIP APPLICATION FORM
MEMBERSHIP- RENEWAL, (ENTER 'YES' IF APPLICABLE): MEMBERSHIP- NEW/REJOIN, (ENTER 'YES' IF APPLICABLE):
NAME:
CALL SIGN: FIRST/LAST
ADDRESS:
CITY/TOWN:
PROVINCE
POSTAL CODE:
DATE OF BIRTH (DD/MM/YY):
HOME PHONE:
CELL PHONE:
BUS. PHONE:
RAC MEMBER? (YES/NO)
E-MAIL ADDRESS:

MEMBERSHIP TYPE

FULL     $25.00 ACCESS TO PHONE PATCH AND CLUB STATION.*
FAMILY $25.00 ACCESS TO PHONE PATCH AND CLUB STATION.*
NOVICE $12.50 ACCESS TO CLUB STATION WHEN ACCOMPANIED BY A FULL MEMBER.*
MAY WE MAKE YOUR INFORMATION PUBLIC IN OUR ON-LINE DATA BASE?
MAY WE ADD YOU TO OUR EMERGENCY FAN-OUT LIST?

ALL MEMBERSHIPS INCLUDE AN E-MAIL COPY OF THE MONTHLY NEWSLETTER. ONLY IF E-MAIL IS UNAVAILABLE WILL ONE BE MAILED.

* CLUB STATION IS CURRENTLY AVAILABLE ON TUESDAY EVENINGS. ARRANGEMENTS WITH AN EXECUTIVE MEMBER CAN PROVIDE ACCESS OUTSIDE THIS TIME SLOT.

SIGNATURE: ____________________ DATE: _______________
PLEASE RETURN THIS COMPLETED FORM WITH PAYMENT, MAKE CHEQUE PAYABLE TO:
BRANTFORD AMATEUR RADIO CLUB
P.O. BOX 25036, BRANTFORD, ON, N3T 6K5

THIS FORM HAS BEEN COMPUTER GENERATED FROM THE WWW.VE3BA.COM WEB SITE.