Laurel ARC 2017 Membership

Callsign

Primary Member Callsign
Name

Primary Member Name
Email Address

Preferred Contact Email Address
Phone

Preferred Contact Phone Number (optional)
ARRL Member? Yes No
Is the Primary Member an ARRL Member?
Primary Member Type Regular Member - $15 Blind Member - $10 Under-21 (oldest ham in household) - $10
Select the type of membership for the primary member in the household.
Additional Family Members - $7.50 each

Additional hams in household
Name, Callsign, ARRL Membership of Additional Family Members
(eg, Hiram Maxim, W1AW, Yes)

List the Names, Callsigns, and ARRL Membership status for Additional Family Members
General Fund Donation
$
Amount to donate to the General Fund
Silent Key Fund Donation
$
Amount to donate to the Silent Key Fund
W3LRC 440 MHz Repeater Fund
$
Amount to donate to the W3LRC 440MHz Repeater Fund
WB3GXW Repeater Dues (Optional) Per Household - $17
Optionally, pay household dues for the WB3GXW 2m/70cm Repeaters
Dues Total