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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: |
| 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. |