Membership Application for the Bellevue Amateur Radio Club
7518 Chandler Hills Dr. , Bellevue, NE 68147-2108
Attn: Tom Huber WDØBFO

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Note:  Items marked with * are OPTIONAL all other fields are required.

Enter membership type that applies: [1] Full ($12/YR) [2] Family ($18/YR) (Submit a application for each member) [3] Student ($6/YR) [4] First time licensee no charge first year.

CALL:       CLASS: In training Technician General Extra       ARRL MEMBER: Yes No Life

EXPIRATION DATE:    VE: Yes No

First Name:   Middle Initial *:   Last Name:

Home Phone:   Cell Phone *:   Work Phone

Employer *:   Birth Date [Year is *]:

Spouse:   Spouse Work Phone *: Cell Phone *:

Address:   City:

State:   Zip:

We put a list of members NAME, CALL, EMAIL and PHONE # on the club's home page.  Do you have any objections?
Yes No A YES will keep your name off the list and not answering this will be a NO answer.

Are you interested in being a club officer, on a committee or have any specific interests or comments ?

[Text limited to 3 rows of 80 characters.  Feel free to use the back or attach another piece of paper.]

Signature:   Date:

Signing this means you are willing to abide by the current Constitution and By-Laws. If you want a copy, contact a club officer or download from the File Share Area.

Rev date: 1/10/2003