Membership Application & Renewal FormOur memberships start Oct 1st, so new member fees are reduced in later quarters

❏ New Regular MembershipOct-Dec $25 / Jan-Mar $20 / Apr-Jun $15 / Jul-Sep $10

❏ Regular Membership Renewal $25(due by October 1)

Name: __________________________________________________ Call Sign: _______________ Address: ________________________________________________________________________ City: ___________________________________ State: ____________ Zip Code: _____________Telephone Number: (____)_______________ E-mail: _____________________________________

(address you wish to receive club information & news)

Are you an ARRL Member: Yes No Years you have held an Amateur Radio license: ________License: Novice Technician (Plus) General Advanced Extra Expiration: ____________Let us know your Amateur Radio interests & modes of operation: (Please check all that apply)

❏ Rag Chewing ❏ Public Service ❏ HF ❏ SSB ❏ Building & Experimenting ❏ APRS ❏ ATV ❏ Field Day ❏ Dxing ❏ VHF/UHF

❏ CW ❏ AM ❏ Hamfest ❏ Contesting ❏ ARES ❏ RACES ❏ PSK-31 ❏ Digital ❏ IRLP ❏ D-Star ❏ Echolink❏ Other ____________________________________________________________________________________________________

I certify that: As a member of the Palmetto Amateur Radio Club Incorporated, I am responsible for my actions and my actions alone. I have read and agreed to abide by all the FCC rules and regulations as codified in Title 47 of the Code of Federal Regulations (CFR), as well as the Palmetto Amateur Radio Club Constitution of the organization. I have never been arrested or convicted of a felony nor placed on supervised probation.

Signature: ___________________________________________________________ Date: _______________________ (The board of directors reserves the right to refuse any applicant without stated cause.)

Please remit this application and dues payment by mail (do not send cash) to the address below, in person at a regular monthly club meeting, or at a sanctioned club event to the Club Secretary:

(Make your check payable to the "Palmetto Amateur Radio Club, Inc.")

Palmetto Amateur Radio Club, Inc. 825 Fairway Drive

Plantation, Florida 33317

Palmetto Amateur Radio Club Official Use Only Application & Dues Received By the Club Secretary: _____________________________________ Date: ____________ Amateur Radio License Checked: O Yes O NoMeets all requirements as a Regular Club Member: O Yes O NoMembership accepted or rejected by (President or Vice President): __________________________ Date: ____________

Comment: ________________________________________________________________________________________

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