N1ME - Pine State Amateur Radio Club

Pine State Amateur Radio Club
Membership Application

Membership Types and Annual Dues: (Please check all that apply)

_____  Full Membership (Voting) - $ 20
_____  Associate Membership (Non-voting) - $ 10
_____  Youth Full Membership (18 & under) - $  5
_____  Youth Associate Membership (12 & under) - FREE

_____  Associate membership for one family member of Full Member - FREE

Amount to be paid $ _____.00

Call Sign: __________   Novice____   Tech____   General____   Advanced____   Extra____
Name: _________________________________________________
Address: _________________________________________________
City: _____________________________________   State: ________   Zip: ____________________
Phone: (______)  ____________-________________
Email: ______________________@___________________.________
Birthday: ____/____/________         ARRL Member?:  YES____   NO____
                MM / DD /  YYYY

Additional Family Member (For FREE Associate Member if applicable)

Call Sign: __________   Novice____   Tech____   General____   Advanced____   Extra____
Name: _________________________________________________
Birthday: ____/____/________         ARRL Member?:  YES____   NO____
                MM / DD /  YYYY

Please make checks payable to "Pine State Amateur Radio Club" and return this form to:

Pine State Amateur Radio Club
c/o Tom Colavito - KB2USA - Secretary
76223 Timbercreek Blvd
Yulee, FL 32097-0657