Four Corners Amateur Radio Club

Central Florida Chapter 2 of the North America DX, Assoc., Inc.

Membership Application

Date______FCC Call Sign ______

Name (first)______(last) ______

Address ______City ______

St. _____Zip ______Phone ______Cell Phone ______

D.O.B. _____/_____/______Email address ______

Lic. Class ______yr. 1st Lic. ______ARRL Y/N NADXA # ______

C.E.R.T. ______ARES ______RACES ______

Active bands and modes: CW SSB RTTY AM FM SSTV ATV SAT. PSK-31

70 cm 220 144 mhz. 6 mtrs. 10, 12, 15, 17, 20, 40, 60, 75/80, 160

Other Clubs:______

Other Hobbies: ______

______

I , ______Will abide by the Constitution and By-Laws of

(Signature of applicant) the Four Corners ARC & NADXA, Inc.

Send dues ($5) Five Dollars with application to club Secretary.

______

(signature of Four Corners ARC President) (Date)

Four Corners Amateur Radio Club Secretary

50989 US 27 Lot 9 Davenport, Florida 33897

Central Fl. Chapter 2 of the NADXA

North America DX Assoc. Inc. www.nadxa.org