Quarter Century Wireless Association Chapter 162, S.E. WI
                    New Member Application

Date : 

Name  : 
Call  :        
Class : 

Home Address   : 
City State Zip : 

Home Phone : 
Work       : 
Cell       : 
Email      :
Spouse     : 

License Expiration Date  : 
QCWA Member Number :
Year you joined QCWA : 
QCWA International Expiration Date : 
ARRL Member : yes/no

Most Used Bands : 

Modes Used (Mark as Yes or No)
  SSB 
  CW 
  FM 
  RTTY 
  AMTOR 
  PACKET 
  PSK 
  QRP 
  Satellite 
  Meteor 
  Aurora 
  Other Modes (specify) 

Types Of Equipment : 

Other Hobbies :                                                            

Occupation Past/Present :  

Dues are  $10.00 annually Jan 1 to Dec 31.
Fill in this form with desired info. We do not sell or publish any of this.

Email it to Chapter Secretary/Treasures after editing.  You can use the Email link
on the Chapter home page at http://qcwa.org/chapter162.htm

You must be a member of QCWA International to join a local Chapter.