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Peace River Radio Association
Amateur Radio Membership Application
Personal Information
Full Name:
Call Sign:
Address:
City, State, ZIP:
Phone:
Email:
Membership Type
Regular – $20/year
Family – $30/year
Student – $10/year
Licensing Information
License Class:
Expiration Date:
Emergency Contact
Name:
Relationship:
Phone:
Payment Method
Cash
Check
Credit Card
Signature:
Date:
Website: www.peaceriverradio.org | Email: [email protected] | Phone: (123) 456-7890
Your information is kept confidential and used solely for club purposes.
Your information is kept confidential and used solely for club purposes.