CHAPTER MEMBERSHIP APPLICATION

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 _________________________________________________________________________



Print and mail to: Gary Sherard - WA5FLV
20 North Plummer
Chanute, KS 66720
(621) 431-1667



We would like the following for our files

Birthday Mo. _____ Day. _____ Year _________       Anniversary Mo. _____ Day _____

OM/XYL Name _______________________________ If Licensed, call _____________________

Other Clubs ____________________________________________________________________

Hobbies _______________________________________________________________________





http://www.qcwa.chapter211-membership-application.htm Last Update: February 7, 2004