P.O. BOX 1541
INDEPENDENCE, MISSOURI 64055
I hereby apply for a New Renewal membership in the Independence FM Amateur Radio Club.
I understand the dues are payable in advance and will expire on June 30th of the following year(s). I also understand that I am under no obligation to renew my membership upon expiration.
GENERAL INFORMATION
My present Amateur Radio Call is: Class: Technician General Extra expires:
I have passed the FCC Morse Code test, 5-WPM (Words Per Minute) Yes No
First Name: Last Name:
Street Address:
City: State: ZIP: Phone Number:
E-Mail Address (if any):
***If you DO NOT want your phone number published in the Official Club Roster, then check here: .***
SPEED DIAL NUMBER(S)
I presently have Speed Dial Number(s):
If you DO NOT have a Speed Dial Number and would like to have one (or wish to have an additional one) please list in the box below the phone number that you want assigned. It cannot be a long distance or toll call from Independence, Missouri. You will be contacted when it is programmed into the repeater controller.
I want these Speed Dial Number(s):
YEARLY CLUB DUES
The Club's present dues are: $20.00 per year. Please renew my membership for: 1 2 3 4 year(s).
TOTAL AMOUNT DUE AT THIS TIME: $
FAMILY MEMBERS
All licensed Amateur Radio Operators that reside in the same household as a full member are entitled to a free membership. Please list all Amateur Radio Operators living at the member's address:
Call: Name: Class: Technician General Extra Relationship:
CLUB PROPERTY
Do you have any club property in your possession? Yes No If Yes please list items below:
Present location of club property in your possession:
FOR CLUB RECORDS ONLY
Current Occupation or Occupation before retiring: Retired: Yes No
Did you participate in any club functions in the past year? Yes No If so, please indicate which ones below:
First club function: Santa-Cali-Gon Field Day Other
Second club function: Field Day Other
If you selected "Other" or have additional events/functions please list them below with dates:
Are you a present member of the ARRL (American Radio Relay League): Yes No
The Independence FM Amateur Radio Club's repeater is equipped with remote links on 10-Meters, 6-Meters, 1.25-Meters, and 70-Centimeters. Do you plan to use the remote links? Yes No , if yes which band will you likely use the most? 10-Meters 6-Meters 1.25-Meters 70-Centimeters
Digital Signature: Date:
