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: ___________