Amateur Radio Community Services Club
Membership Application


Club dues are $10.00 per individual and make checks payable to ARCS and mail to:

ARCS
Post Office Box 75
Paintsville
Kentucky
41240-0075


YOUR FULL NAME : _____________________________________________

CALL SIGN:|___|___|___|___|___|___|

LICENSE CLASS: TEC [__]  GEN [__]  ADV [__]  EXA [__]

MAILING ADDRESS : ____________________________________________

PHYSICAL ADDRESS : ___________________________________________


CITY : _______________________________________________________

COUNTY : _____________________________________________________

STATE :
Kentucky [__] ________________________________________
[If you are in Kentucky, just check it]

ZIP CODE : ___________________________________________________

PHONE NUMBER(s) : ____________________________________________

E-MAIL ADDRESS : _____________________________________________

BIRTHDAY : (Optional): (MM/DD/YYYY) [____/____/_______]

ARRL MEMBER : Yes [__]   No [__]   Wanna be? YES I would [__]

Do not write below
Received on :
___/____/______ By : ______________________  Call : ______________
New or Renewel?
New [__]   Renewel [__]
Comments : _________________________________________________________________________