Membership Application
Iowa City Amateur Radio Club, Inc.
PO Box 4
Iowa City, IA 52244-0004

Please Print Clearly


Callsign: ___________  Name: _____________________________________    Date: ____________

    License Class:  [  ] Tech    [  ] General    [  ] Advanced    [  ] Extra

Spouse Callsign: ___________  Spouse Name: _____________________________________________

    License Class:  [  ] Tech    [  ] General    [  ] Advanced    [  ] Extra

Family Member Name(s) and Callsign(s): _________________________________________________

________________________________________________________________________________________

Address: _______________________________________________________________________________

City: ______________________________________  State: _____  Zip: _____________-_________

Phone (H): (_____)_____________  (W): (_____)_____________  (Cell): (_____)_____________

Email Address (Please print): __________________________________________________________


Would you like to be added to the ICARC email reflector?       [  ] Yes     [  ] No

Are you a member of the American Radio Relay League (ARRL)?    [  ] Yes     [  ] No

Are you a Volunteer Examiner (VE)?  Check if yes:              [  ] ARRL VE [  ] W5YI VE

Are you interested in participating in Public Service Events?  [  ] Yes     [  ] No


Dues (per calendar year, prorated for part year for new members only):
  Note:  Senior rate is for those 75 years of age and over.

  Regular:        [  ] $20.00      Senior:        [  ]  $10.00     Student: [  ]  $10.00

  Regular Family: [  ] $30.00      Senior Family: [  ]  $15.00




===================  Club Use Only - Do Not Write Below This Line  ====================


Received: ___________    Treasurer: ___________    Entered: ___________


Last updated April 21, 2017 by KØCF