The North Coast Amateur Radio Club                                                    __ This is a change of 
    P.O. Box 30529 Cleveland, Ohio 44130                                                       information (or NEW)
                                                                                                                             __  This is a renewal, 
     APPLICATION FOR MEMBERSHIP                                                                            use the same info
       (Subject to Trustees’ Approval)                                                                             __  Renew family members

     DATE: ____________________, 2010

     CALL SIGN: _____________________
          CLASS:    Nov  -  Tech  -  Plus  -  Gen  -  Adv  -  Ex  -  None     EXPIRES?:  ___________________
                                  (circle one)
     LAST NAME : __________________________________________________________________

     FIRST NAME ( for roster ) :  _______________________________  MIDDLE INITIAL : ________

     ADDRESS _____________________________________________________________________

     CITY:  _____________________________________________    COUNTY:  _________________

     STATE :  ____________________________________                ZIP: ____________ - __________
                                                    ( We MUST have your ZIP + 4 to mail the newsletter )

     PHONE:   ( ______ )   _____ - ________________  UNLISTED?: Y / N,  MAY WE PUBLISH?: Y / N                                                                                                                    (circle one)    (circle one)
     E - MAIL ADDRESS:  _____________________________________________________________
                    Do you wish to receive the newsletter at your E - Mail address?     Y  /  N   ( circle one )
     DO YOU HAVE EXISTING AUTODIAL PHONE NUMBER ( S )  ?

             SLOT # _________    PHONE NUMBER  ( _______ )   ___________________________

             SLOT # _________    PHONE NUMBER  ( _______ )   ___________________________

     ARRL MEMBER?   Y  /  N                ARRL MEMBERSHIP EXPIRES: ___________________
                               ( circle one )
     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?    Mary Lou, K8MLS  ( 216 )  267 - 5083  or  E - Mail:   k8mls@roadrunner.com  

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Updated  05/24/2010

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