Name ______________________________________ Call _____________________

Address ______________________ License Class ___________ ARRL Member Y / N

City, State _______________________ Zip _____________ Phone

_______________

Email Address: _______________________________________________________

____ Regular Membership $ 20.00

____ SWL Membership $ 20.00

____ Extra Family Membership $ 6.00

____ Bunker Buddie $ 5.00

____ Auto Patch w/1 Speed Slot $ 25.00

____ Extra Speed Slots $ 5.00

$ _______ Total Paid by Club Member

For Example: Regular Member, with A/P and Bunker Buddy (20+25+5) = $ 50.00

_____________________________________________________________________