OREGON TUALATIN VALLEY

AMATEUR RADIO CLUB

880 N.E. 25th Ave., Suite 2-160

Hillsboro, OR 97124-6258

WWW.OTVARC.ORG

OTVARC@gmail.com

MEMBERSHIP APPLICATION

To insure that our records are accurate and up to date, please fill out completely.

Name _________________________________ Call ____________ Date __________

  License Class:    [ ] Not Yet    [ ] Technician   [ ] General   [ ] Advanced    [ ] Extra

Address _______________________________________ E-mail ________________

City ___________________ State _____ Zip _____________ Phone (____)________

Spouse’s Name ____________ Spouse’s Call ______  Spouse Member? [ ] Yes [ ] No   

Your Occupation ______________ Company __________ Work Phone (___)_________

OTVARC Life Member? [ ] Yes [ ] No            Your DOB ___/___/___

ARRL Member? [ ] Yes [ ] No                         ARRL Life member? [ ] Yes [ ] No

ARRL Appointment? ____________            ARES Member?  [ ] Yes [ ] No

VE Certified? [ ] Yes [ ] No   Which Organization [ ] ARRL [ ] W5YI [ ] Other _________

Please indicate interests that you wish to support.

[ ] Bunny Hunting   [ ] Camping   [ ] Contest   [ ] Education   [ ] Elections  [ ] Elmer  [ ] Emergency Service

[ ] Equipment loan  [ ] FIELD DAY   [ ] Membership  [ ] OSCILLATOR   [ ] Packet  

[ ] Project Night   [ ] Public Awareness  [ ] Public Service   [ ] Repeater  [ ] RFI  

[ ] SEA-PAC  [ ] Social   [ ] VE Testing   [ ] VHF/UHF

[ ] Renewal $20.00 for 2010   [ ] $25 for Family Membership (at same address)

[ ] New Member - $12.00 including $2 application fee through December, 2010.

[ ] New Member - $32.00 including $2 application fee through December, 2011.

[ ] Family Member - Add $5.00 per additional member at same address.

INCLUDE COMPLETED FORM FOR EACH FAMILY MEMBER

RETURN COMPLETED FORM(S) AND YOUR CHECK TO CLUB BOX ABOVE.

Questions? Everett Curry W6ABM or 503.522.7142.

Updated: July 7, 2010