Kings County Repeater Association

Amateur Radio Club

Brooklyn, New York

APPLICATION FOR MEMBERSHIP

Name ________________________________________________________________________

Call ____________ Class _______________ License Expires on ________/_____/________

Address_______________________________________________________________________

City ________________________ State _________ Postal Code _____________________

Home Phone (____)_____-________ Date of Birth: (Month) _________ (Day) ________

E-Mail Address to receive the Newsletter ___________________________________________

Are there other Amateur Radio Operators in your family? [ ] Yes [ ] No

If so, would you like any of them to be a Family Member of the KCRA? [ ] Yes [ ] No

[ ] New Member (Associate Member 6 months/Full Member 6 months) ……

……….……………………………………………… ..................................@ $35 __________

[ ] Full Member's renewal dues per year ……………………………………... $35 __________

[ ] Family Member's dues per person per year ……………………………….. $10 __________

                                                                                                                        Total $ __________

Upon receipt of the KCRA membership card, the applicant agrees to abide by the KCRA by-laws, The KCRA Repeater Operator’s Guidelines, and the FCC rules.

Applicant's signature ___________________________________ Date ______/_____/______

Please make check or money order payable to the Kings County Repeater Association. Return this application and appropriate fee to our Membership Chairperson at:

Don LaSala (W2DON)

6735 Ridge Blvd. Apt 4Q

Brooklyn, NY 11220

For use by the Membership Committee:

Amount paid $ ______ by [ ] cash or [ ] check, and applicant's check # ________

Membership Card # ______ issued _______/____/_____ [ ] by mail [ ] in person.

Membership Type NEW____________RENEW_________

Associate Membership Date ___________ Regular Membership Date ___________