Membership Application – W8BI Home of the Dayton Amateur Radio Association

DARA Membership Application

Member Information

Name

First

Last

Membership Type

Full Member - $10 Per year
Associate Member - $10 Per year
Additional Family Member (Each) - $3 Per yearr

Member ID

Call Sign

License Class

License Expires

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email

Birth Date

Phone Numbers

Home

Cell

Work

Reasons for Joining the Club

Referred By (if applicable)

First

Last

Preferred Communication

Email
Text Message

Confirmation

Agreement

I have read and agree to the club rules and code of conduct. I understand that failure to follow club rules may result in termination from the club.

Signature

Clear Signature

Phone Type Date

Date of Application