P.O. Box 73

Moffett Field, CA 94035-0073

Last Name____________________, First Name____________________MI____

FCC Callsign_____________________ ARRL Member: Y / N

Licence Class: SWL / Nov / Tec / Tec+ / Gen / Adv / Ext

Santa Clara County Emergency Responder Id Card Expires On: _____________

Ames Phone:_____________ Ames Mailstop:_________ Bldg/Room #________

Pager Number:_________________

E-mail Address:____________________________________________________

Membership Class: Regular / Sponsored / Honorary

Work Status: Active CS / Retired CS / NASA Contractor / Research Associate /

Grant Recipient / Other

Home Phone:_________________

Home Address: ___________________________________________________

___________________________________________________

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Home Station: 6m / 2m base / 2m mobile / 2m HT / 220 base /

220 mobile / 220 HT / 440 base / 440 mobile / 440 HT /

80 HF / 40 HF / 30 HF / 20 HF / 17 HF / 15 HF / 12 HF / 10 HF

VHF Packet / HF Packet / Home BBS: __________________

Other_____________________________________________

Comments:______________________________________________________

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Dues are $12/yr prorated @ $1/month Due 01 January

Make check payable to "Ames Amateur Radio Club".

Return to club secretary or mail to club P.O. Box above. (AARC Form 960816)