Date
Name
Callsign
Address
Address2
CITY
ZIP
Home Phone number
Cell Number
Email
Birthday
Reason for Joining (Optional)
How long have you been a Ham
Have you ever been convicted of a crime ( Excluding Traffic Offenses )? If so Please Explain.(I.E., Date of
conviction, type of conviction, county or city, court, ETC.) Note: Giving false information on this application
will result in immediate dismissal from the club or your not being considered for membership, whichever
applicable. Please enter your answer below.
STATE
I agree to the above (typing name in this box is the equivalent to your signature.)
Russell County Amateur Radio Club, Inc.
Membership Application