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) ___________________________________________________
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
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) _____________________________________________________
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) _____________________________________________________
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:
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