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QCWA NEOSHO VALLEY CHAPTER 211 Membership Application and Information Sheet I hereby apply for membership in the Neosho Valley Chapter of the Quarter Century Wireless Association. I agree to support the purposes of the Chapter and abide by its Bylaws. Call Letters _____________________ License Expiration Date ______________________________QCWA Number __________________ QCWA Membership expiration date ___________________ Name _________________________________________________________________________ Address ________________________________ City ___________________________ State ___ Zip ______________ Telephone ( __ __ __ ) __ __ __ - __ __ __ __ Annual Dues: $10.00 QCWA Certificates held: 50 year ___ 60 Year ___ Others ______________ Signed _________________________________________________________________________
We would like the following for our files Birthday Mo. _____ Day. _____ Year _________ Anniversary Mo. _____ Day _____ OM/XYL Name _______________________________ If Licensed, call _____________________ Other Clubs ____________________________________________________________________ Hobbies _______________________________________________________________________
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