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Print this application, fill it out and send to: Loma Pioneer Repeater Club |
LPRC MEMBERSHIP APPLICATION
Name:___________________________ Handle: _____________________________
Address:_____________________________________________ Phone: ____________
City:____________________ State:____ Zip:_______--_____(include 4 digit suffix)
Callsign:___________ Class of license:__________ Expiration date:_________
If you are not listed in the Callbook or QRZ.COM, please attach a photocopy of your license!
1) Do you want your phone number to appear in the club roster? (Y/N) _____________
2) Are you an ARRL member? (Y/N) _____________
3) Are you an ARRL life member? (Y/N) ____________
4) Please provide your e-mail address if you
want to list it with the club
and get "your callsign"@lprc.net for email. ________________________
5) Do you have Internet access to www.lprc.net? (Y/N) _________
The items 1-4 appear in the club roster unless indicated otherwise. The club
roster is published twice a year.
STATEMENT OF FEES AND CHARGES
| 1) Initiation Fee for new member ($10.00) |
$_____________ |
| 2) Regular dues for continuing or new member ($30.00) |
$_____________ |
| 3) Additional family members over 18 years old ($20.00 per individual) |
$_____________ |
| 4) Additional family members under 18 years old ($5.00 per individual) |
$_____________ |
Total dollars enclosed: $_____________
LPRC Use Only
Approved ( Y / N ) Autodial # _____ Paging # _______ Mailbox # ______ DVR # ______
Date: __________ By: _______________________________
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