put in your information after each line.
send this to jpawlan@yahoo.com
make the Subject line:  memberform


Date filled out: 
Last Name: 
First Name: 
Call: 
Street: 
City: 
State: 
Zipcode: 
Home Phone: 
Work Phone (leave blank if not applicable): 
Cell Phone: 
Email address: 

Modes: 
Examples: SSB, CW, FM, WSJT, and Satellite

Place an X after bands where you are active or where you plan to be active:
HF: 
6m: 
2m: 
220MHz: 
440MHz: 
900MHz: 
1.2GHz: 
2.3GHz: 
3GHz: 
5.7GHz: 
10GHz: 
24GHz: 
47GHz: 
77GHz: 

Check if you are a member of these organizations:
ARRL member?:  
WSWSS member?: