ACLR

Last Name:___________________________First Name:____________________________MI:_______

Street:___________________________________________________________Apt:_________________

City, State:_____________________________________________ZipCode:_______________________

Home Phone:_____________________________________Birthdate:____________________________

E-mail address:__________________________________Date of Application:_____________________

Callsign:__________________________________Class:______________________________________ 


Please list all members of your household, including their birthdates.


1.____________________________________________________________________________________________
   Last name,  First name                   Birthdate        Relationship      Call      Class  

2.____________________________________________________________________________________________
   Last name,   First name                  Birthdate        Relationship      Call      Class   

3.____________________________________________________________________________________________   
    Last name,  First name                  Birthdate        Relationship      Call      Class   

4.____________________________________________________________________________________________
    Last name,  First name                  Birthdate        Relationship      Call      Class   

5.____________________________________________________________________________________________
    Last name,  First name                  Birthdate        Relationship      Call      Class


Type of Membership:

   ____Family/Household $30.00 ____Regular $30.00
   ____Handicap $20.00*              ____Child(under 18) $20.00*

*Handicap must have doctor's statement listing type of handicap. For child membership, the oldest ham in the household must be under 18.

Please mail this completed application, a check or money order for $30.00*; and copies of all ham licenses for your household. After processing your paperwork, your welcome packet will be forwarded to you. If you have any questions please call: (773) 735-6257 or (630) 497-2755 Thank you and welcome to ACLR!