SLCARC Membership Form

SALT LAKE CROSSROADS AMATEUR RADIO CLUB

Membership Application

Total # of Family Applicants at the same residence: ____________
Fees: $5 for first family member; $3 for each additional = $ ________ by cash or check

Mail to 1949 Yale Avenue, Salt Lake City, UT 84108. Write checks to Val Hicken.

Primary Member, if multiple family members at the same residence:
First Name: ________________________ MI: ____ Last Name: ______________________ Callsign: ____________

Gender: Male Female Occupation (optional) ___________________________________________________

Residential Address: _______________________________________________________________________________ City: _________________________________ County: ___________________ State: ________ Zip:______________ Mailing Address if different from Residential: ___________________________________________________________

Home Phone: _______________________________

Cell Phone: _________________________________

May the Club text you notices of Nets ___________

Work Phone (optional) : _____________________________ Cell Carrier: ______________________________________Meetings ___________ Incident Callout ____________

Email: ___________________________________________________________________________________________

Permission to include in the Club directory, including online (circle one): YES or NO

xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

2nd Member: First Name: ______________________ MI: ___ Last Name: ________________ Callsign: _________ Gender: Male Female Occupation (optional) ___________________________________________________

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Address: same as Primary person above
Home Phone: _______________________________
Cell Phone: _________________________________
May the Club text you notices of Nets ___________
Email: ___________________________________________________________________________________________

Work Phone (optional) : _____________________________ Cell Carrier: ______________________________________Meetings ___________ Incident Callout ____________

Permission to include in the Club directory, including online (circle one): YES or NO

OVER FOR MORE MEMBERS in the same family at the same residence.

I/We apply for membership into the Salt Lake Crossroads Amateur Radio Club, agreeing to abide by the Constitution and By-Laws thereof.

Signature: _________________________________________________ Date: _____________________

FOR CLUB SECRETARY USE: Date of Approval by President ___________________________

– Over for Side 2: Additional Family Members at the same residence –

xxxxxxxxxxxxxxx Side 2: Additional Family Members at the same residence xxxxxxxxxxxxxxx

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First Name: ________________________ MI: ____ Last Name: ______________________ Callsign: _____________ Gender: Male Female Occupation (optional) _____________________________________________________

Address: same as Primary person on Side 1

Home Phone: _______________________________

Cell Phone: _________________________________

May the Club text you notices of Nets ___________

Work Phone (optional) : _____________________________ Cell Carrier: ______________________________________Meetings ___________ Incident Callout ____________

Email: ___________________________________________________________________________________________

Permission to include in the Club directory, including online (circle one): YES or NO

xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

First Name: ________________________ MI: ____ Last Name: ______________________ Callsign: _____________ Gender: Male Female Occupation (optional) _____________________________________________________

page2image8440

Address: same as Primary person on Side 1

Home Phone: _______________________________

Cell Phone: _________________________________

May the Club text you notices of Nets ___________

Work Phone (optional) : _____________________________ Cell Carrier: ______________________________________Meetings ___________ Incident Callout ____________

Email: ___________________________________________________________________________________________

Permission to include in the Club directory, including online (circle one): YES or NO

xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

First Name: ________________________ MI: ____ Last Name: ______________________ Callsign: _____________ Gender: Male Female Occupation (optional) _____________________________________________________

page2image14176

Address: same as Primary person on Side 1
Home Phone: _______________________________
Cell Phone: _________________________________
May the Club text you notices of Nets ___________
Email: ___________________________________________________________________________________________ Permission to include in the Club directory, including online (circle one): YES or NO

Work Phone (optional) : _____________________________ Cell Carrier: ______________________________________Meetings ___________ Incident Callout ____________

SEE SIDE 1 FOR SIGNATURE OF THE PRIMARY MEMBER

To Download a copy of this form go to:

https://slcarc.org/wp-content/uploads/2019/06/ARC-SL-Crossroads-Membership-Application-2018_10_27.doc

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