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Application for Membership

Please print out this form, complete and sign, and send with payment to:
Joanna Dilley, K6YL; PO Box 399; San Carlos, CA 94070

Name used on the air:                                                                                         

Call Sign:                                        

Full Name:                                                                                                            
                        (First) (Initial) (Last)

Address:                                                                                                               

City, State, Zip:                                                                                                     

Area Code, Telephone:                    /                                         
(OK to publish in Club Roster? ___Y ___N)

E-Mail Address:                                                                    
(OK to publish in Club Roster and Web Site? ___Y ___N)

Member ARRL? ____ License Class ____ Years Licensed ____ Full-Time Student? ____

Other call signs held, past and present_______________________________________

I hereby apply for membership in the NCCC and certify that I am qualified for the membership class indicated. I agree to abide by the By-Laws of the NCCC and to notify the Secretary-Treasurer of any change in my membership status.

Signature:                                                                                               

Date:                                                                   

Nominated By:

Name:                                                      Call:                                          Date:                       

Name:                                                      Call:                                          Date:                       

Name:                                                      Call:                                          Date:                       

Brief description of station:                                                                                                       

                                                                                                                                                   

Operating preferences: CW _________% Phone __________

% RTTY ___________%  Other _________% (mode?)

Contest experience and awards:                                                                                               

                                                                                                                                                   

Favorite Contests:                                                                                                                      

Other comments:                                                                                                                        

                                                                                                                                                   

                                                                                                                                                   

Do you wish to order an NCCC badge (cost $20)? ____Y ____N

Name _______________________ and Call Sign ______________ to appear on badge.

NCCC Dues Schedule (Voluntary)
Recommended Fees

Member Class Date Joined or Renewed Dues Member Class Date Joined or Renewed Dues
Full Member Jul 1 to Sept 30 $24.00 Family, Student, Associate Jul 1 to Sept 30 $12.00
Full Member Oct 1 to Dec 31 $18.00 Family, Student, Associate Oct 1 to Dec 31 $9.00
Full Member Jan 1 to Mar 31 $12.00 Family, Student, Associate Jan 1 to Mar 31 $6.00
Full Member   Apr 1 to June 30 $6.00  Family, Student, Associate   Apr 1 to June 30 $3.00

Note that while dues are voluntary, payment of at least the amount shown in the table above is necessary to receive personal club awards.

Amount Paid:                                                            Date:                               

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