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 ___________