2011 CONTRA COSTA REPEATER ASSOCIATION MEMBERSHIP APPLICATION

WEB SITE http://ccra.us/

 

       Application For Single Membership:_______             Member number:                _________

       Application For Family Membership:_______                   Date approved:            _________

Primary Member Call:______________ Name:____________________                                  $20.00

Family Member Call:__________________Name:_____________________Relationship:________10.00

Family Member Call:__________________Name:_____________________Relationship:________10.00

Family Member Call:__________________Name:_____________________Relationship:________ -0-

Family Member Call:__________________Name:_____________________Relationship:________ -0-

Family Member Call:__________________Name:_____________________Relationship:________ -0-

Total:                                                                                                                               $_________

(Family members include those Amateur Radio Operators residing in the same household.)

 

Home address:______________________________  

City: ___________________________

ZIP: ___________

Mailing Address:      ______________________________________________________________________

                      (if different than Home address)

Home Phone:  (      )                                                        

 ___   Please don’t release my home phone number

Cell Phone Number:(      )____________________  

 ___   Please don’t release my cell phone number

Work Telephone:(      )_______________________

 ___   Please don’t release my work phone number

 

List amateur organizations (such as RACES, ARRL, MDARC, etc..):  _____________________________

Are you willing to work public service events such as walk-a-thons, bike rides, ect..?          _  YES  _  NO

Are you available to work emergencies as called up by the Sheriff or OES?                        _  YES   _  NO

Are you interested in repeater technical operations, such as construction, and maintance? _  YES  _  NO

 

Todays Date:  ____________________ Signature:  ___________________________________

2011 Membership Dues Paid:_____   Date:________  Executive Board Member Initials:________

CCRA Membership Contact Information:  N6KLS@yahoo.com

Revised 1/18/2010