The North Coast Amateur Radio Club ___ This is a change of
c/o Dan Sarama, NCARC Treasurer information (or NEW)
4103 Keswick Dr. ___ This is a renewal,
Brunswick, OH 44212-7004 use the same info
___ Renew family members
APPLICATION / RENEWAL - NCARC MEMBERSHIP
DATE: ____________________, 202___
CALL SIGN: _____________________
CLASS: (circle one) Nov - Tech - Plus - Gen - Adv - Ex - None EXPIRES: ________________
FIRST NAME: _________________________ MID INITIAL: ____ LAST NAME: _________________________________
Preferred First Name for the Website MINI Roster: ______________
ADDRESS: _____________________________________________________________________
CITY: _____________________________________________ COUNTY: _________________
STATE: ____________________________________ ZIP: ____________ - __________
PHONE: HOME: ( ) - ________________ UNLISTED?: Y / N, MAY WE PUBLISH?: Y / N
PHONE: CELL: ( ) - ________________ UNLISTED?: Y / N, MAY WE PUBLISH?: Y / N
Email ADDRESS: _____________________________________________________________
Do you authorize the Club to correspond to you via Email? Y / N
ARRL MEMBER? Y / N ARRL MEMBERSHIP EXPIRES: ___________________
TYPE OF MEMBERSHIP REQUESTED: ( check one )
__ INDIVIDUAL MEMBERSHIP -- $20.00 annual dues (July 1 thru June 30)
**NEW** members (first-time) may prorate their dues:
July/$20.00, August/$18.50, September/$17.00, October/$15.00,
November/$13.50, December/$12.00, January/$10.00, February/$8.50,
March/$7.00, April/$25.00 *, May/$23.50 *, June/$22.00 *
* means new members will be valid until June 30 of following year.
__ SENIOR (over 64) / JUNIOR (under 18) MEMBERSHIP -- $12.00
__ FAMILY MEMBERS - $2 per year. Family member must reside at same address
as an individual member and may not be prorated. CALL _______ Name _______________
Any Questions? Send e-mail to Dan, kb8a@outlook.com
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