W9MQB TRI-COUNTY AMATEUR RADIO
CLUB MEMBERSHIP FORM

Yearly dues are $10.00 for the first ham in the household and $5.00 for each additional member.

If you wish to pay dues via mail, please print this form, fill it out, and mail it and your payment to:

TCARC – W9MQB Membership
PO Box 321
Fort Atkinson, WI 53538-0321
(Note: No meetings are held during the months of June, July or August.)

Name:      
Call Sign:       License Class:       Birthday:

Spouse's Name:
Spouse's Call Sign:       License Class:       Birthday:

Address:
                 
City:                    

Telephone Number:       Cell Phone:

Email:

ARRL Member:       ARES/RACES Member: * ICS 100/700 Required

Amateur Radio Related Courses: (List course(s) attended and Year)